Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

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

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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.

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Clinical Practice Guidelines for Providers (PDF)

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: 10/01/2014 Title: Sylvant (Siltuximab)
Revision Date: 12/01/2016 Document: BI459:00
CPT Code(s): J2860
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)    Sylvant is used to treat multi-centric Castleman’s disease (MCD)

2)    Sylvant is a specialty medication covered under the medical benefit.

3)    Sylvant (Siltuximab) requires prior authorization.
Medical Statement

Sylvant is considered medically necessary for members meeting the following criteria:

1)    Diagnosis of multi-centric Castleman’s disease (MCD)  AND

2)    Member is human immunodeficiency virus (HIV) negative  AND

3)    Member is human herpesvirus-8 (HHV-8) negative

 

Reauthorization after 12 months will be provided if:

1)    Member is HIV negative and HHV-8 negative AND

2)    Member has not experienced treatment failure defines as disease progression based on increase in symptoms, radiologic progression, or deterioration in performance status.

Codes Used In This BI:

J2860     Siltuximab Injection, 10mg (code recycled/reinstated on 1/1/16)
Reference

1)    Sylvant Prescribing Information.  Janssen Biotech, Inc.  June 2014

2)    Clinical Pharmacology.  Accessed online September 2014.
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.
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