Medical Policy

Effective Date:08/04/2010 Title:Neumega (Oprelvekin)
Revision Date:10/01/2015 Document:BI271:00
CPT Code(s):J2355
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)    Neumega (Oprelvekin) is an injectable medication used to treat low platelets after chemotherapy.

2)    Neumega requires pre-authorization.

3)    Neumega is available through specialty pharmacy.

Medical Statement

1)    Neumega (Oprelvekin) is covered for the treatment of thrombocytopenia (D69.59) in members with no myeloid tumors who meet the following criteria:

a)    18 years of age and over and;

b)    Documented thrombocytopenia (<= 20,000) after previous chemotherapy and;

c)    Is receiving myelosupressive and not myeloablative chemotherapy.

 

Codes Used In This BI:

J2355             Injection Oprelvekin 5 mg.

Limits

Limited to 21-day supply per course.

Reference
Intentially left empty
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.