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)    Torisel (temsirolimus) is an injectable medication which is used in the treatment of advanced kidney cancer, certain soft tissue sarcoma, and endometrial carcinoma.

2)    Torisel is covered under the medical benefit as a specialty drug for the conditions listed above.

QualChoice considers treatment of other cancers with Torisel to be experimental and investigational and is not covered.

Torisel is considered medically necessary in the treatment of the following diagnoses:

1)    Advanced renal cell carcinoma OR

2)    Soft Tissue Sarcoma – PEComa/Recurrent Angiomyolipoma/Lymphangioleiomyomatosis OR

3)    Endometrial Carcinoma

Codes Used In This BI:

J9330           Inj, Temsirolimus, 1mg

1)    Torisel Prescribing Information. Pfizer Inc. Philadelphia, PA.  July 2016.

2)    Clinical Pharmacology. Accessed online 5/22/17

3)    NCCN Drugs & Biologics Compendium.  Accessed online 5/22/2017

Addendum:

1.     Effective 07/01/2017:  Updated to include covered diagnoses of soft tissue sarcoma – PEComa/Recurrent angiomyolipoma/lymphangioleiomyomatosis and endometrial carcinoma.

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

The Federal Employees Health Benefit Program (FEHBP) has different coverage. Please see refer to your policy brochure.