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