Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

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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.

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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: 01/01/2024	Title: Imjudo
Revision Date:	Document: BI731:00
CPT Code(s): J9347
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) Imjudo (tremelimumab-actl) requires prior authorization. 2) Imjudo is indicated for the treatment of unresectable hepatocellular carcinoma (uHCC) in combination with durvalumab and metastatic non-small cell lung cancer (NSCLC). 3) Imjudo is covered under the medical benefit.
Medical Statement
Imjudo is considered medically necessary when the following criteria are met: I. Initial Approval Criteria a. Non-Small Cell Lung Cancer (must meet all): i. Diagnosis of NSCLC; ii. Prescribed by or in consultation with an oncologist; iii. Age > 18 years; iv. Prescribed in combination with durvalumab and platinum-based therapy; v. Dosing is consistent with FDA-labeling b. Hepatocellular Carcinoma (must meet all): i. Diagnosis of unresectable, liver-confined, or metastatic hepatocellular carcinoma; ii. Prescribed by or in consultation with an oncologist; iii. Age 18 years; iv. Prescribed in combination with durvalumab; v. Dosing is consistent with FDA-labeling; Initial Approval Duration: 6 months II. Continued Therapy a. Member is responding to therapy; b. Dosing is consistent with FDA-labeling Continued Therapy Approval Duration: 12 months Codes Used In This BI: 1) J9347 – Injection, tremelimumab-actl, 1mg
Reference
1) Imjudo Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; November 2022. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761270s000lbl.pdf. Accessed December 1, 2022. 2) 2. National Comprehensive Cancer Network. Non-Small Cell Lung Cancer Version 6.2022. Available at: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed December 2, 2022. 3) 3. National Comprehensive Cancer Network. Hepatobiliary Cancers Version 3.2022. Available at: https://www.nccn.org/professionals/physician_gls/pdf/hepatobiliary.pdf. Accessed December 2, 2022.
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.