Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

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.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

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:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2012 Title: Adcetris (Brentuximab)
Revision Date: 10/01/2019 Document: BI334:00
CPT Code(s): J9042
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)    Adcetris (Brentuximab) requires pre-authorization.

2)    Adcetris is considered a specialty medication.

3)    Adcetris is used to treat several different types of lymphoma and mycosis fungoides/Sezary syndrome.


Medical Statement

Adcetris is considered medically necessary for members > 18 years old who meet the following criteria:

a)    Diagnosis of Hodgkin’s lymphoma (C81.00-C81.99) who have failed autologous stem cell transplant (ASCT) or, if not a candidate for ASCT, have failed at least two prior multi-agent chemotherapy regimens; OR

b)    Non-Hodgkin T-Cell Lymphomas

i)   Diagnosis of one of the following:

(1)  Peripheral T-cell lymphoma (PTCL);

(2)  Breast implant-associated anaplastic large cell lymphoma (stage II-IV);

(3)  Adult T-cell leukemia/lymphoma

(a)  Failure of at least one prior multi-agent chemotherapy regimen; OR

(b)  Subsequent therapy after high dose therapy/autologous stem cell rescue (HDT/ASCR)

c)    Primary Cutaneous CD30+ T-cell Lymphomproliferative Disorder

i)   Diagnosis of one of the following:

(1)  CD 30-positive pcALCL

(2)  Cutaneous ALCL with regional nodes (excludes sALCL)

(3)  Lymphomatoid papulosis (LyP) withextensivelesions if relapsed/refractory to retreatment with primary treatment or retreatment with alternative regimen not used for primary treatment

d)    Mycosis Fungoides/Sezary Syndrome

i)   Diagnosis of one of CD 30-expressing mycosis fungoides or Sezary syndrome

Codes Used In This BI:

J9042   Injection, brentuximab vedotin, 1mg


Limits

Adcetris is limited to a maximum of 16 cycles.


Reference
1) Adcetris Product Information. Seattle Genetics. August 2011. 2) Clinical Pharmacology Online. “brentuximab”, retrieved November 2011. 3) NCCN Guidelines. Accessed online 5/6/2019.
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.