Medical Policy

Effective Date:05/01/2012 Title:Erwinaze (Asparaginase Erwinia Chrysanthemi)
Revision Date:10/01/2015 Document:BI359:00
CPT Code(s):J9019
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)    Erwinaze (Asparaginase Erwinia Chrysanthemi) requires prior authorization.

2)    Erwinaze is used to treat acute lymphoblastic leukemia.

3)    Erwinaze is covered under the medical benefit as a specialty drug.

Medical Statement

Erwinaze (Axitinib) is considered medically necessary for patients who meet the following criteria:

1)    Diagnosis of acute lymphoblastic leukemia (C91.00, C91.02);   AND

2)    Patient has NOT had a history of any of the following:

a)    History of serious hypersensitivity reaction to Erwinaze, including anaphylaxis

b)    History of serous pancreatitis with prior L-Asparaginase therapy

c)    History of serious thrombosis with prior L-Asparaginase therapy

d)    History of serious hemorrhagic events with prior L-Asparaginase therapy.   AND

3)     Patient has hypersensitivity to E. coli-derived Asparaginase.

Limits
Intentially left empty
Reference

1)    Erwinaze Product Information.  EUSA Pharma, Inc.  November 2011

2)    Clinical Pharmacology.  Erwinaze.  Accessed online March 2012.

3)    Duval M, et al.  Comparison of E coli-Asparaginase with Erwinia-Asparaginase in the treatment of childhood lymphoid malignancies:  results of a randomized European organization of research and treatment of cancer-Children’s Leukemia Group phase 3 trial.  Blood 2001; 99:2734-39.

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.