Coverage Policies

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

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, 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: 03/01/2019 Title: Lutathera (lutetium Lu 177 dotatate)
Revision Date: Document: BI602:00
CPT Code(s): A9513
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)    Lutathera (lutetium Lu 177 dotatate) requires prior authorization.

2)    Lutathera is used in the treatment of specific gastroenteropancreatic neuroendocrine tumors (NETs).


Medical Statement

Lutathera (lutetium Lu 177 dotatate) is considered medically necessary for members meeting the following criteria:

 

1)    Neuroendocrine Tumors (must meet all):

a.    Diagnosis of a somatostatin receptor-positive NET of one of the following origins (i or ii):

                                          i.    Gastrointestinal tract or pancreas;

                                        ii.    Lung or thymus (off-label)

b.    Prescribed by or in consultation with an oncologist;

c.    Age > 18 years of age;

d.    Disease is metastatic or locally advanced, and unresectable;

e.    Member experienced disease progression while on a long-acting somatostatin analog (e.g. octreotide, lanreotide);

f.     Members has not received > 4 doses of Lutathera;

g.    Dose does not exceed 7.4GBq (200mCi) every 8 weeks, up to a total of 4 doses.

Approval duration: 32 weeks (no more than 4 total doses)

 

2)    Pheochromocytoma/Paraganglioma (off-label) (must meet all):

a.    Diagnosis of s somatostatin receptor-positive pheochromocytoma/paraganglioma;

b.    Prescribed by or in consultation with an oncologist;

c.    Disease is metastatic or locally advanced, and unresectable;

d.    Member has not received > 4 doses of Lutathera;

e.    Dose does not exceed 7.4GBq (200 mCi) every 8 weeks, up to a total of 4 doses.

Approval duration: 32 weeks (no more than 4 total doses).

 

Codes Used In This BI:

 

A9513 – Lutetium Lu 177, dotatate, therapeutic, 1 millicurie


Limits

Lutathera is limited to no more than 4 total doses.


Reference

1)    Lutathera Prescribing Information. Advanced Accelerator Applications USA, Inc. January 2018.

2)    NCCN Drugs & Biologics Compendium. Accessed online 1/14/19.


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.