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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: 09/01/2017 Title: Imfinzi (Durvalumab)
Revision Date: 12/01/2020 Document: BI556:00
CPT Code(s): C9492, J9173
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)    Imfinzi (Durvalumab) requires prior authorization.

2)    Imfinzi is used to treat advanced bladder cancer and lung cancer.


Medical Statement

Imfinzi (Durvalumab) is considered medically necessary for patients who meet the following conditions:

Urothelial Carcinoma

1)    Patient is 18 years of age or older; AND

2)    Diagnosis of locally advanced or metastatic urothelial carcinoma; AND

3)    Experienced disease progression during or following platinum-containing chemotherapy; OR

4)    Experienced disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

Non-Small Cell Lung Cancer

1)    Patient is 18 years of age or older; AND

2)    Diagnosis of unresectable stage III non-small cell lung cancer (NSCLC); AND

3)    Disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy.

Extensive Stage Small Cell Lung Cancer (ES-SCLC)

1)    Diagnosis of ES-SCLC AND

Prescribed as first-line treatment with (etoposide with either carboplatin or cisplatin) followed by maintenance Imfinzi.

 

Codes Used In This BI:

C9492     Imfinzi (Durvalumab (code deleted 1/1/19)

J9173      Imfinzi (Durvalumab (new code 1/1/19)


Reference

1)    Clinical Pharmacology. Accessed online August 2018.

2)    NCCN Drugs & Biologics Compendium. Accessed online August 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.
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