Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 06/01/2023	Title: Elahere (mirvetuximab soravtansine)
Revision Date:	Document: BI715:00
CPT Code(s): C9146
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Elahere requires prior authorization. 2) Elahere is used to treat ovarian cancer. 3) Elahere is covered under the medical benefit.
Medical Statement
Elahere is considered medically necessary when the following criteria are met: Initial Approval Criteria Ovarian Cancer A) Diagnosis of epithelial ovarian, fallopian tube, or primary peritoneal cancer; B) Prescribed by or in consultation with an oncologist; C) Age ≥ 18 years; D) Member meets all of the following parameters a. FRα positive ovarian cancer determined by the Ventana FOLR1 (Folate Receptor 1/Folate Receptor Alpha) Assay; b. Platinum resistant ovarian cancer; c. Received at least 1 but no more than 3 prior systemic lines of anticancer therapy, including at least 1 line of therapy containing bevacizumab; E) Documentation of current actual body weight in kg and height in cm; F) Request meets one of the following a. Dose does not exceed 6mg/kg dosed based on adjusted ideal body weight b. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). Approval Duration: 6 months Continuation of Therapy Ovarian Cancer A) Member is responding positively to therapy; B) Documentation of current actual body weight in kg; Approval Duration: 12 months Codes Used In This BI: 1) C9146 – Ijnection, mirvetuximab soravtansine-gynx, 1mg
Reference
1) Elahere Prescribing Information: Waltham, MA: ImmunoGen, Inc. November 2022. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761310s000lbl.pdf. Accessed January 6, 2023 2) Mirvetuximab In: National Comprehensive Cancer Network Drugs and Biologics Compendium. Available at: http://www.nccn.org/professionals/drug_compendium. Accessed. January 6, 2023. 3) A Study of Mirvetuximab Soravtansine in Platinum-Resistant, Advanced High-Grade Epithelial Ovarian, Primary Peritoneal, or Fallopian Tube Cancers With High Folate Receptor-Alpha Expression (SORAYA). ClinicalTrials.gov. Last updated January 23, 2023. Available at: https://clinicaltrials.gov/ct2/show/NCT04296890. Accessed January 23, 2023.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.