| Effective Date:09/01/2017 |
Title:Bavencio (Avelumab)
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| Revision Date:12/01/2020
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Document:BI555:00
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| CPT Code(s):J9023
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Public Statement
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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)
Bavencio (avelumab)
requires prior authorization.
2)
Bavencio is used to treat
Merkel Cell Carcinoma (MCC), advanced bladder cancer,advanced renal cell
carcinoma, and gestational trophoblastic neoplasia.
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Medical Statement
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Bavencio (avelumab) is considered medically necessary for members meeting the
following criteria:
Merkel Cell Carcinoma
1)
Diagnosis of metastatic,
Stage IV Merkel Cell Carcinoma (MCC) AND
2)
Refractory to
chemotherapy.
Bladder Cancer
1)
Diagnosis of local
advanced or metastatic urothelial carcinoma AND
2)
Disease progression
during or following platinum-containing chemotherapy OR
3)
Have disease progression
within 12 months of neoadjuvant or adjuvant treatment with platinum-containing
chemotherapy.
Renal Cell Carcinoma
1)
Diagnosis of advanced RCC
(e.g. relapse or stage IV disease) AND
2)
Age > 18 years AND
3)
Prescribed as first-line
therapy with Inlyta
Gestational Trophoblastic Neoplasia
1)
Diagnosis of gestational
trophoblastic neoplasia; AND
2)
Patient is 18 years of
age or older; AND
3)
Prescribed as first-line
therapy in combination with Inlyta
Codes
Used In This BI:
J9023
Injection, avelumab, 10 mg
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Limits
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Intentially left empty
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Reference
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1)
Bavencio Prescribing
Information. EMD Seronoa, Inc. Rockland, MA.
June 2020
2)
Clinical Pharmacology.
Accessed October 2020
3)
NCCN Drugs & Biological
Compendium. Accessed October 2021.
Addendum:
1)
Effective 10/01/2017:
Added new HCPCS code (C9491) to policy.
2)
Effective 1/1/2018:
2018 Code Updates. Updated Codes Used in This BI section to reflect
new/deleted CPT/HCPCS codes. The following code was deleted 1/1/18: C9491. This
code was replaced with the following new code effective 1/1/18: J9023.
3)
Effective 12/01/2020:
Updated to include coverage criteria for Renal Cell Carcinoma.
4)
Effective 12/01/2021:
Added coverage criteria for gestational trophoblastic neoplasia.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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