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Adcetris® (brentuximab vedotin)
Policy Number: VP-0004
Intravenous
Last Review Date: 08/01/2024
Date of Origin: 02/28/2012
Dates Reviewed: 06/2012, 09/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 04/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 12/2019, 03/2020, 06/2020, 09/2020, 12/2020, 03/2021, 06/2021, 09/2021, 12/2021, 03/2022, 06/2022, 09/2022, 12/2022, 03/2023, 06/2023, 09/2023, 12/2023, 03/2024, 05/2024, 8/2024
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization 1,5,7,15,18,21
Coverage will be provided for 6 months and may be renewed (unless otherwise specified).
- Treatment of previously untreated Pediatric Classical Hodgkin Lymphoma (cHL) as a component of Bv-AVE-PC (brentuximab vedotin, doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide) has a maximum of 5 doses.
- Pediatric cHL as a component of AEPA (brentuximab vedotin, etoposide, prednisone, doxorubicin) has a maximum of 2 cycles (6 doses).
- Pediatric cHL as a component of CAPDAC (cyclophosphamide, brentuximab vedotin, prednisone, dacarbazine) has a maximum of 4 cycles (8 doses).
- Adult cHL in combination with nivolumab has a maximum of 8 doses.
- Pediatric cHL in combination with nivolumab has a maximum of 4 doses
- Pediatric and Adult cHL in combination with bendamustine has a maximum of 6 doses.
- Adult cHL in combination with ifosfamide, carboplatin, and etoposide (ICE) has a maximum of 4 doses.
- Adult cHL in combination with etoposide, cyclophosphamide, doxorubicin, dacarbazine, dexamethasone (BrECADD) has a maximum of 6 doses.
- Adult cHL post-auto HSCT, Primary Cutaneous Lymphomas (excluding use with bendamustine), single agent use for T-Cell Lymphomas (excluding Systemic ALCL), and Pediatric cHL (excluding use with Bv-AVE-PC, AEPA, CAPDAC, nivolumab, or bendamustine) has a maximum of 16 doses.
- Treatment of previously untreated Adult Stage III or IV cHL in combination with AVD (doxorubicin, vinblastine, and dacarbazine) has a maximum of 12 doses.
- Treatment of T-cell lymphomas in combination with cyclophosphamide, doxorubicin, and prednisone (CHP) has a maximum of 8 doses.
- Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
- Adcetris 50 mg single-dose vial: 9 vials every 28 days
- Max Units (per dose and over time) [HCPCS Unit]:
Classical Hodgkin Lymphoma:
- 1350 billable units every 84 days
All other indications:
- 200 billable units every 21 days
- Initial Approval Criteria 1
Coverage is provided in the following conditions:
- Patient is at least 18 years of age (unless otherwise specified); AND
Universal Criteria 1
- Patient must not be receiving concomitant bleomycin; AND
- Patient does not have severe renal impairment (i.e., CrCl <30 mL/min); AND
- Patient does not have moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment; AND
- Patient has CD30-positive disease; AND
Adult Classic Hodgkin Lymphoma (cHL) † Ф 1,2,4,12-14
- Used as single agent therapy; AND
- Used as consolidation/maintenance therapy post-autologous hematopoietic stem cell transplant (auto-HSCT) in patients at high risk* for relapse or progression † ‡; OR
- Patient has relapsed disease after failure of auto-HSCT or after failure of at least 2 (two) prior multi-agent chemotherapy regimens in patients who are not auto-HSCT candidates †; OR
- Used as subsequent systemic therapy (if not previously used) for relapsed or refractory disease ‡; OR
- Used as palliative therapy for relapsed or refractory disease ‡; AND
-
- Patient is > 60 years of age; OR
- Patient has poor performance status; OR
- Patient has substantial comorbidities; OR
- Used in combination with bendamustine; AND
- Used as subsequent systemic therapy (if not previously used) for relapsed or refractory disease ‡; OR
- Used in combination with nivolumab; AND
- Used as subsequent systemic therapy (if not previously used) for relapsed or refractory disease ‡; OR
- Used in combination with dacarbazine; AND
- Used as primary treatment in patients with low ejection fraction ‡; AND
- Patient is > 60 years of age; OR
- Patient has poor performance status; OR
- Patient has substantial comorbidities; OR
- Used as primary treatment in patients with low ejection fraction ‡; AND
- Used in combination with ifosfamide, carboplatin, and etoposide (ICE); AND
- Used as subsequent systemic therapy (if not previously used) for relapsed or refractory disease ‡; OR
- Used in combination with doxorubicin, vinblastine, and dacarbazine (AVD); AND
- Used in combination with dacarbazine; AND
-
- Patient is > 60 years of age; OR
- Patient has poor performance status; OR
- Patient has substantial comorbidities; OR
- Used in combination with etoposide, cyclophosphamide, doxorubicin, dacarbazine, dexamethasone (BrECADD); AND
- Used as primary treatment for stage III-IV disease; AND
- Patient is 18-61 years of age
*High risk for relapse or progression may be defined as:
|
Pediatric Classic Hodgkin Lymphoma (cHL) † ‡ Ф 1,2,24
- Patient is ≤ 18 years of age*; AND
- Used as re-induction or subsequent therapy (if not previously used); AND
-
- Patient has relapsed or refractory disease; AND
- Used in combination with bendamustine, nivolumab, or gemcitabine; AND
- Used in patients heavily pretreated with platinum or anthracycline-based chemotherapy; OR
- Used if a decrease in cardiac function is observed; OR
- Used as maintenance therapy following high-dose therapy and autologous stem cell rescue (HDT/ASCR); AND
- Used as a single agent for relapsed or refractory high-risk disease (i.e., progressive disease, refractory disease, or relapse within 1 year of original diagnosis); OR
- Used as primary therapy in patients with high risk disease**; AND
- Used as a component of AEPA (brentuximab vedotin, etoposide, prednisone, doxorubicin) regimen; OR
- Used as a component of Bv-AVE-PC (brentuximab vedotin, doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide) †; AND
-
- Patient is at least 2 years of age; OR
- Used as additional treatment following primary treatment with AEPA regimen in patients with high risk disease**; AND
-
- Used as a component of CAPDAC (cyclophosphamide, brentuximab vedotin, prednisone, dacarbazine) regimen
*Pediatric Hodgkin Lymphoma may be applicable to adolescent and young adult (AYA) patients up to the age of 39 years.
**High risk disease may be defined as: Stage IIB with bulk or E-lesions (involvement of extra-lymphatic tissue), Stage IIIA with bulk AND E-lesions, or Stage IIIB or IV disease.
Pediatric Aggressive Mature B-Cell Lymphomas (Primary Mediastinal Large B-Cell Lymphoma) ‡ 2,21
- Patient is ≤ 18 years of age*; AND
- Used in combination with nivolumab or pembrolizumab; AND
- Used as consolidation/additional therapy if a partial response was achieved after therapy for relapsed or refractory disease
*Pediatric Aggressive Mature B-Cell Lymphoma may be applicable to adolescent and young adult (AYA) patients older than 18 years of age and less than 39 years of age, who are treated in the pediatric oncology setting.
T-Cell Lymphomas 1-3,15,16
- Peripheral T-Cell Lymphomas (PTCL)
- Used as a single agent for relapsed or refractory disease as subsequent OR as initial palliative intent therapy for one of the following:
-
-
-
- Systemic Anaplastic Large Cell Lymphoma (sALCL) † Ф
- Peripheral T-Cell Lymphoma not otherwise specified (PTCL-NOS) ‡ Ф
- Angioimmunoblastic T-cell Lymphoma (AITL) ‡ Ф; OR
-
-
- Used in combination with cyclophosphamide, doxorubicin, and prednisone (CHP) as initial therapy for previously untreated:
-
-
- Systemic Anaplastic Large Cell Lymphoma (sALCL) † Ф
- Peripheral T-Cell Lymphoma not otherwise specified (PTCL-NOS) † Ф
- Angioimmunoblastic T-cell Lymphoma (AITL) † Ф
- Enteropathy-Associated T-cell Lymphoma (EATL) ‡ Ф
- Monomorphic Epitheliotropic Intestinal T-cell Lymphoma (MEITL) ‡
- Nodal Peripheral T-cell Lymphoma with TFH phenotype (PTCL, TFH) ‡
- Follicular T-cell Lymphoma (FTCL) ‡
-
-
-
- Breast-Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) ‡
- Used as adjuvant therapy as a single agent or in combination with cyclophosphamide, doxorubicin, and prednisone (CHP); AND
- Patient has localized disease to the capsule, implant, or breast with residual disease following an incomplete excision or partial capsulectomy, if either node positive or radiation therapy is not feasible; OR
- Patient has extended disease (stage II-IV); OR
- Used as subsequent therapy for relapsed or refractory disease as a single agent
- Adult T-Cell Leukemia/Lymphoma ‡ Ф
- Used as a single agent; AND
-
- Used as subsequent therapy for nonresponders to first-line therapy for chronic high risk, acute, or lymphoma subtypes; OR
- Used in combination with cyclophosphamide, doxorubicin, and prednisone (CHP); AND
- Used as first-line therapy for chronic high risk, acute or lymphoma subtypes; OR
- Used as continued treatment in responders to first-line therapy for acute or lymphoma subtypes; OR
- Used as additional therapy for nonresponders to first-line therapy for chronic low risk or smoldering symptomatic subtype; OR
- Used as additional therapy for nonresponders to first-line therapy with zidovudine and interferon for chronic high risk subtype; OR
- Used as additional therapy (if not previously used) for nonresponders to first-line therapy for acute subtype
- Extranodal NK/T-Cell Lymphoma ‡ Ф
- Used as a single agent for relapsed or refractory disease; AND
- Used following additional therapy with an alternate combination chemotherapy regimen (asparaginase-based) not previously used
- Hepatosplenic T-Cell Lymphoma ‡
- Used as single-agent therapy; AND
- Used for refractory disease as subsequent therapy after 2 (two) first-line therapy regimens
Primary Cutaneous Lymphomas 1,2,17
- Mycosis Fungoides (MF) † Ф/Sezary Syndrome (SS) ‡
- Used as single agent systemic therapy; AND
-
- Used as primary therapy (excluding use in patients with stage IA disease); OR
- Used as subsequent therapy; OR
-
- Used in combination with bendamustine; AND
-
- Used as primary treatment; AND
- Patient has stage IVA2 non-Sezary or stage IVB visceral disease (solid organ); OR
- Patient has generalized cutaneous or extracutaneous lesions with large cell transformation (LCT); AND
- Used in combination with skin-directed therapy; OR
- Used as subsequent treatment; AND
- Used for disease refractory to multiple previous therapies; AND
- Used in combination with skin-directed therapy; AND
- Patient has stage IIB Mycosis Fungoides with generalized tumor lesions; OR
- Patient has stage III Mycosis Fungoides; OR
- Patient has limited cutaneous lesions with large cell transformation (LCT); OR
- Used in combination with skin-directed therapy; AND
- Used for relapsed or persistent disease; AND
- Patient has stage IVA2 non-Sezary or stage IVB visceral disease (solid organ); OR
- Patient has LCT with generalized cutaneous or extracutaneous lesions; AND
- Used in combination with skin-directed therapy
- Used for disease refractory to multiple previous therapies; AND
- Used as primary treatment; AND
- Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders ‡ Ф
- Used as a single agent; AND
-
- Patient has primary cutaneous anaplastic large cell lymphoma (pcALCL) † Ф; OR
- Patient has cutaneous ALCL with regional node (N1) (excludes systemic ALCL); OR
- Patient has lymphomatoid papulosis (LyP) with extensive lesions that is relapsed or refractory to treatment options (e.g., clinical trial, observation, retreatment with primary treatment, or treatment with alternative regimen not used for primary treatment); OR
- Used in combination with cyclophosphamide, doxorubicin, and prednisone (CHP); AND
- Patient has cutaneous ALCL with regional node (N1) (excludes systemic ALCL)
B-Cell Lymphomas ‡ 2,11
- Diffuse Large B-Cell Lymphoma (DLBCL), HIV-Related B-Cell Lymphomas (i.e., DLBCL, primary effusion lymphoma, or HHV8-positive DLBCL, not otherwise specified), or High Grade B-Cell Lymphomas
-
- Used as a single agent as subsequent therapy if no intention to proceed to transplant; AND
-
- Used for relapsed disease >12 months after completion of first-line therapy; OR
- Used for primary refractory disease (partial response, no response, or progression) or relapsed disease <12 months after completion of first-line therapy*; OR
- Monomorphic Post-Transplant Lymphoproliferative Disorders (PTLD)
-
- Used as a single agent as subsequent therapy for B-cell type disease if no intention to proceed to transplant; AND
-
- Used for relapsed disease >12 months after completion of initial treatment with chemoimmunotherapy; OR
- Used for primary refractory disease (partial response, no response, or progression) or relapsed disease <12 months after completion of initial treatment with chemoimmunotherapy*; OR
- Used as alternative systemic therapy (if not previously used) for relapsed/refractory disease*
*Note: Only applies to patients who are non-candidates for CAR T-cell therapy.
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1
Coverage may be renewed based upon the following criteria:
- Patient continues to meet the universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
- Disease response with treatment defined by stabilization of disease or decrease in size of tumor or tumor spread; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: peripheral neuropathy, anaphylaxis and infusion reactions, hematologic toxicities (thrombocytopenia, neutropenia, and anemia), serious infections, opportunistic infections, tumor lysis syndrome, hepatotoxicity, pulmonary toxicity, serious dermatologic reactions, gastrointestinal complications, uncontrolled hyperglycemia, etc.; AND
- Patient has been evaluated for the presence of progressive multifocal leukoencephalopathy (PML) and has been found to be negative; AND
Pediatric cHL (in combination with Bv-AVE-PC, AEPA, CAPDAC, nivolumab, or bendamustine)
- Coverage may not be renewed.
Pediatric cHL (all other treatment settings/regimens)
- Patient has not exceeded a maximum of 16 (sixteen) doses.
Adult cHL (in combination with nivolumab, bendamustine, ICE, BrECADD)
- Coverage may not be renewed.
Adult cHL (post-auto HSCT consolidation)
- Patient has not exceeded a maximum of 16 (sixteen) doses.
Adult cHL (previously untreated stage III or IV in combination with AVD)
- Patient has not exceeded a maximum of 12 (twelve) doses.
Primary Cutaneous Lymphomas (excluding in combination with bendamustine)
- Patient has not exceeded a maximum of 16 (sixteen) doses.
Single Agent Treatment of T-cell Lymphomas (excluding Systemic ALCL)
- Patient has not exceeded a maximum of 16 (sixteen) doses.
T-Cell Lymphomas (in combination with CHP)
- Coverage may not be renewed.
- Dosage/Administration 1,5,7,15,18-21,23,25-31,35-38
Indication |
Dose |
Adult cHL |
Previously untreated stage III or IV in combination with doxorubicin, vinblastine, and dacarbazine (AVD) Administer 1.2 mg/kg (up to 120 mg) by intravenous infusion every 2 weeks until a maximum of 12 doses, disease progression, or unacceptable toxicity
Consolidation post auto HSCT as a single agent Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until a maximum of 16 cycles, disease progression, or unacceptable toxicity
Relapsed disease in combination with bendamustine Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 6 doses
Relapsed disease in combination with nivolumab Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 8 doses
Relapsed disease in combination with ifosfamide, carboplatin, and etoposide (ICE) Administer 1.5 mg/kg (up to 150 mg) by intravenous infusion on day 1 and 8 every 3 weeks for a maximum of 4 doses
Primary therapy in combination with dacarbazine Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks in combination for 12 doses, followed by monotherapy until disease progression or unacceptable toxicity
Primary therapy in combination with etoposide, cyclophosphamide, doxorubicin, dacarbazine, dexamethasone (BrECADD) Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 6 cycles All other treatment settings/regimens: Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until disease progression or unacceptable toxicity |
Primary Cutaneous Lymphomas |
Single agent therapy for Mycosis Fungoides (MF)/Sezary Syndrome (SS) Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until a maximum of 16 cycles, disease progression, or unacceptable toxicity In combination with bendamustine for Mycosis Fungoides (MF)/Sezary Syndrome (SS) Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until disease progression, or unacceptable toxicity
Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until a maximum of 16 cycles, disease progression, or unacceptable toxicity
|
Pediatric cHL |
Previously untreated high-risk disease in combination with Bv-AVE-PC (doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide) Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 5 doses
Primary therapy for high-risk disease as a component of AEPA (brentuximab vedotin, etoposide, prednisone, doxorubicin) Administer 1.2 mg/kg (up to 120 mg) by intravenous infusion on days 1, 8, 15 every 28 days for 2 cycles
Additional treatment as a component of CAPDAC (cyclophosphamide, brentuximab vedotin, prednisone, dacarbazine) Administer 1.2 mg/kg (up to 120 mg) by intravenous infusion on days 1 and 8 every 21 days for 4 cycles
In combination with nivolumab Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 4 doses
In combination with bendamustine Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 6 doses
All other treatment settings/regimens Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until a maximum of 16 cycles, disease progression, or unacceptable toxicity |
T-Cell Lymphomas |
In combination with cyclophosphamide, doxorubicin, and prednisone (CHP) Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks for a maximum of 6 to 8 doses
Single agent treatment for relapsed Systemic ALCL: Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until disease progression or unacceptable toxicity
Single agent treatment for all other settings: Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until a maximum of 16 cycles, disease progression, or unacceptable toxicity |
All other indications |
Administer 1.8 mg/kg (up to 180 mg) by intravenous infusion every 3 weeks until disease progression or unacceptable toxicity |
- Billing Code/Availability Information
HCPCS Code:
- J9042 – Injection, brentuximab vedotin, 1 mg; 1 billable unit = 1 mg
NDC:
- Adcetris 50 mg powder for injection in a single-dose vial: 51144-0050-xx
- References
- Adcetris [package insert]. Bothell, WA; Seagen, Inc; June 2023. Accessed July 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for brentuximab vedotin. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed July 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) T-Cell Lymphomas. Version 4.2024. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed July 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Hodgkin Lymphoma. Version 3.2024. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed July 2024.
- Duvic M, Tetzlaff MT, Gangar P, et al. Results of a Phase II trial of brentuximab vedotin for CD30+ cutaneous T-cell lymphoma and lymphomatoid papulosis. J Clin Oncol 2015; 33:3759-65.
- Horwitz SM, Advani RH, Bartlett NL, et al. Objective responses in relapsed T-cell lymphomas with single-agent brentuximab vedotin. Blood 2014;123:3095-3100.
- Alderuccio, JP., Desai, A., Yepes, M.M., et al. Frontline brentuximab vedotin in breast implant-associated anaplastic large-cell lymphoma. Clin Case Rep 2018; 6(4): 634-637. Doi:10.1002/ccr3.1382.
- Fahrenbruch R, Kintzel P, Bott AM, et al. Dose Rounding of Biologic and Cytotoxic Anticancer Agents: A Position Statement of the Hematology/Oncology Pharmacy Association. J Oncol Pract. 2018 Mar;14(3):e130-e136.
- Hematology/Oncology Pharmacy Association (Updated January 2022). Intravenous Cancer Drug Waste Issue Brief. Retrieved from https://www.hoparx.org/documents/65/HOPA_Drug_Waste_Issue_Brief_-_Updated_01.19.22_FINAL.pdf
- Bach PB, Conti RM, Muller RJ, et al. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016 Feb 29;352:i788.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) B-Cell Lymphomas. Version 2.2024. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed July 2024.
- Connors JM, Jurczak W, Straus DJ, et al. Brentuximab Vedotin with Chemotherapy for Stage III or IV Hodgkin’s Lymphoma [published correction appears in N Engl J Med. 2018 Mar 1;378(9):878]. N Engl J Med. 2018;378(4):331-344.
- Moskowitz CH, Nademanee A, Masszi T, et al. Brentuximab vedotin as consolidation therapy after autologous stem-cell transplantation in patients with Hodgkin’s lymphoma at risk of relapse or progression (AETHERA): a randomized, double-blind, placebo-controlled, phase 3 trial. Lancet. 2015;385(9980):1853-1862.
- Younes A, Gopal AK, Smith SE, et al. Results of a pivotal phase II study of brentuximab vedotin for patients with relapsed or refractory Hodgkin’s lymphoma. J Clin Oncol. 2012;30(18):2183-2189.
- Horwitz S, O’Connor OA, Pro B, et al. Brentuximab vedotin with chemotherapy for CD30-positive peripheral T-cell lymphoma (ECHELON-2): a global, double-blind, randomized, phase 3 trial. Lancet. 2019;393(10168):229-240.
- Pro B, Advani R, Brice P, et al. Brentuximab vedotin (SGN-35) in patients with relapsed or refractory systemic anaplastic large-cell lymphoma: results of a phase II study. J Clin Oncol. 2012;30(18):2190-2196.
- Prince HM, Kim YH, Horwitz SM, et al. Brentuximab vedotin or physician’s choice in CD30-positive cutaneous T-cell lymphoma (ALCANZA): an international, open-label, randomized, phase 3, multicentre trial. Lancet. 2017;390(10094):555-566.
- Cole PD, McCarten KM, Pei Q, et al. Brentuximab vedotin with gemcitabine for paediatric and young adult patients with relapsed or refractory Hodgkin’s lymphoma (AHOD1221): a Children’s Oncology Group, multicentre single-arm, phase 1-2 trial. Lancet Oncol. 2018 Sep;19(9):1229-1238. Doi: 10.1016/S1470-2045(18)30426-1. Epub 2018 Aug 16.
- Jacobsen ED, Sharman JP, Oki Y, et al. Brentuximab vedotin demonstrates objective responses in a phase 2 study of relapsed/refractory DLBCL with variable CD30 expression. Blood. 2015 Feb 26;125(9):1394-402. Doi: 10.1182/blood-2014-09-598763. Epub 2015 Jan 8.
- Chang VA, Wang HY, Reid EG. Activity of brentuximab vedotin in AIDS-related primary effusion lymphoma. Blood Adv. 2019 Mar 12;3(5):766-768. Doi: 10.1182/bloodadvances.2018026351.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Pediatric Aggressive Mature B-Cell Lymphomas. Version 1.2024. National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed July 2024.
- Zinzani PL, Pellegrini C, Chiappella A, et al. Brentuximab vedotin in relapsed primary mediastinal large B-cell lymphoma: results from a phase 2 clinical trial. Blood. 2017 Apr 20;129(16):2328-2330. doi: 10.1182/blood-2017-01-764258.
- Zinzani PL, Santoro A, Gritti G, et al. Nivolumab Combined With Brentuximab Vedotin for Relapsed/Refractory Primary Mediastinal Large B-Cell Lymphoma: Efficacy and Safety From the Phase II CheckMate 436 Study. J Clin Oncol. 2019 Nov 20;37(33):3081-3089. doi: 10.1200/JCO.19.01492.
- Castellino SM, Pei Q, Parsons SK, et al. Brentuximab Vedotin with Chemotherapy in Pediatric High-Risk Hodgkin's Lymphoma. N Engl J Med. 2022 Nov 3;387(18):1649-1660. doi: 10.1056/NEJMoa2206660.
- Cole PD, Mauz-Körholz C, Mascarin M, et al. Nivolumab and brentuximab vedotin (BV)-based, response‐adapted treatment in children, adolescents, and young adults (CAYA) with standard-risk relapsed/refractory classical Hodgkin lymphoma (R/R cHL): Primary analysis. J Clin Oncol 2020;38:8013.
- Harker-Murray P, Mauz-Körholz C, Leblanc T, et al. Nivolumab and brentuximab vedotin with or without bendamustine for R/R Hodgkin lymphoma in children, adolescents, and young adults. Blood. 2023 Apr 27;141(17):2075-2084. doi: 10.1182/blood.2022017118. PMID: 36564047.
- O’Connor OA, Lue JK, Sawas A, et al. Brentuximab vedotin plus bendamustine in relapsed or refractory Hodgkin’s lymphoma: an international, multicenter, single-arm, phase 1-2 trial. Lancet Oncol 2018;19:257-266.
- Lynch RC, Cassaday RD, Smith SD, et al. Dose-dense brentuximab vedotin plus ifosfamide, carboplatin, and etoposide for second-line treatment of relapsed or refractory classical Hodgkin lymphoma: a single centre, phase 1/2 study. Lancet Haematol 2021;8:e562-e571.
- Friedberg JW, Forero-Torres A, Bordoni RE, et al. Frontline brentuximab vedotin in combination with dacarbazine or bendamustine in patients aged ≥60 years with HL. Blood 2017;130:2829-2837.
- Friedberg JW, Forero-Torres A, Holkova B, et al. Long-term follow-up of brentuximab vedotin ± dacarbazine as first line therapy in elderly patients with Hodgkin lymphoma [abstract]. J Clin Oncol 2018;36 (Suppl 15):Abstract 7542.
- Advani RH, Moskowitz AJ, Bartlett NL, et al. Brentuximab vedotin in combination with nivolumab in relapsed or refractory Hodgkin lymphoma: 3-year study results. Blood 2021;138:427-438
- Borchmann P, Moccia AA, Greil R, et al. BreECADD Is non-inferior to eBEACOPP in patients with advanced stage classical Hodgkin Lymphoma: Efficacy results of the GHSG Phase III HD21 trial. Hematological Oncology 2023;41:881-882.
- Eichenauer DA, Plütschow A, Kreissl S, et al. Incorporation of brentuximab vedotin into first-line treatment of advanced classical Hodgkin's lymphoma: final analysis of a phase 2 randomised trial by the German Hodgkin Study Group. Lancet Oncol. 2017 Dec; 18(12): 1680-1687. doi: 10.1016/S1470-2045(17)30696-4. Epub 2017 Nov 10. PMID: 29133014.
- Evens AM, Advani RH, Helenowski IB, et al. Multicenter Phase II Study of Sequential Brentuximab Vedotin and Doxorubicin, Vinblastine, and Dacarbazine Chemotherapy for Older Patients With Untreated Classical Hodgkin Lymphoma. J Clin Oncol. 2018 Oct 20;36(30):3015-3022. doi: 10.1200/JCO.2018.79.0139. Epub 2018 Sep 4.
- Aubrais R, Bouabdallah K, Chartier L, et al. Salvage therapy with brentuximab-vedotin and bendamustine for patients with R/R PTCL: a retrospective study from the LYSA group. Blood Adv. 2023 Oct 10; 7(19): 5733–5742. Published online 2022 Dec 10. doi: 10.1182/bloodadvances.2022008524
- Metzger ML, Link MP, Billett AL, et al. Excellent Outcome for Pediatric Patients With High-Risk Hodgkin Lymphoma Treated With Brentuximab Vedotin and Risk-Adapted Residual Node Radiation. J Clin Oncol. 2021 Jul 10;39(20):2276-2283. doi: 10.1200/JCO.20.03286. Epub 2021 Apr 7. PMID: 33826362; PMCID: PMC8260923.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Brentuximab vedotin: T-Cell Lymphomas Chemotherapy Order Template, TCL23. National Comprehensive Cancer Network, 2024. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed July 2024.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Brentuximab vedotin: T-Cell Lymphomas Chemotherapy Order Template, TCL12. National Comprehensive Cancer Network, 2024. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed July 2024.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
C81.10 |
Nodular sclerosis Hodgkin lymphoma, unspecified site |
C81.11 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.12 |
Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes |
C81.13 |
Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.14 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.15 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.16 |
Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes |
C81.17 |
Nodular sclerosis Hodgkin lymphoma, spleen |
C81.18 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites |
C81.19 |
Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites |
C81.20 |
Mixed cellularity Hodgkin lymphoma, unspecified site |
C81.21 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.22 |
Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes |
C81.23 |
Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.24 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.25 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.26 |
Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes |
C81.27 |
Mixed cellularity Hodgkin lymphoma, spleen |
C81.28 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites |
C81.29 |
Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites |
C81.30 |
Lymphocyte depleted Hodgkin lymphoma, unspecified site |
C81.31 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.32 |
Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes |
C81.33 |
Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.34 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.35 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.36 |
Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes |
C81.37 |
Lymphocyte depleted Hodgkin lymphoma, spleen |
C81.38 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites |
C81.39 |
Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites |
C81.40 |
Lymphocyte-rich Hodgkin lymphoma, unspecified site |
C81.41 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.42 |
Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes |
C81.43 |
Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.44 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.45 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.46 |
Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes |
C81.47 |
Lymphocyte-rich Hodgkin lymphoma, spleen |
C81.48 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites |
C81.49 |
Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites |
C81.70 |
Other Hodgkin lymphoma unspecified site |
C81.71 |
Other Hodgkin lymphoma lymph nodes of head, face, and neck |
C81.72 |
Other Hodgkin lymphoma intrathoracic lymph nodes |
C81.73 |
Other Hodgkin lymphoma intra-abdominal lymph nodes |
C81.74 |
Other Hodgkin lymphoma lymph nodes of axilla and upper limb |
C81.75 |
Other Hodgkin lymphoma lymph nodes of inguinal region and lower limb |
C81.76 |
Other Hodgkin lymphoma intrapelvic lymph nodes |
C81.77 |
Other Hodgkin lymphoma spleen |
C81.78 |
Other Hodgkin lymphoma lymph nodes of multiple sites |
C81.79 |
Other Hodgkin lymphoma extranodal and solid organ sites |
C81.90 |
Hodgkin lymphoma, unspecified, unspecified site |
C81.91 |
Hodgkin lymphoma, unspecified, lymph nodes of head, face and neck |
C81.92 |
Hodgkin lymphoma, unspecified, intrathoracic lymph nodes |
C81.93 |
Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes |
C81.94 |
Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb |
C81.95 |
Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
C81.96 |
Hodgkin lymphoma, unspecified, intrapelvic lymph nodes |
C81.97 |
Hodgkin lymphoma, unspecified, spleen |
C81.98 |
Hodgkin lymphoma, unspecified, lymph nodes of multiple sites |
C81.99 |
Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
C83.30 |
Diffuse large B-cell lymphoma unspecified site |
C83.31 |
Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck |
C83.32 |
Diffuse large B-cell lymphoma intrathoracic lymph nodes |
C83.33 |
Diffuse large B-cell lymphoma intra-abdominal lymph nodes |
C83.34 |
Diffuse large B-cell lymphoma lymph nodes of axilla and upper limb |
C83.35 |
Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.36 |
Diffuse large B-cell lymphoma intrapelvic lymph nodes |
C83.37 |
Diffuse large B-cell lymphoma, spleen |
C83.38 |
Diffuse large B-cell lymphoma lymph nodes of multiple sites |
C83.39 |
Diffuse large B-cell lymphoma extranodal and solid organ sites |
C83.80 |
Other non-follicular lymphoma, unspecified site |
C83.81 |
Other non-follicular lymphoma, lymph nodes of head, face and neck |
C83.82 |
Other non-follicular lymphoma, intrathoracic lymph nodes |
C83.83 |
Other non-follicular lymphoma, intra-abdominal lymph nodes |
C83.84 |
Other non-follicular lymphoma, lymph nodes of axilla and upper limb |
C83.85 |
Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb |
C83.86 |
Other non-follicular lymphoma, intrapelvic lymph nodes |
C83.87 |
Other non-follicular lymphoma, spleen |
C83.88 |
Other non-follicular lymphoma, lymph nodes of multiple sites |
C83.89 |
Other non-follicular lymphoma, extranodal and solid organ sites |
C83.90 |
Non-follicular (diffuse) lymphoma, unspecified site |
C83.91 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of head, face, and neck |
C83.92 |
Non-follicular (diffuse) lymphoma, unspecified intrathoracic lymph nodes |
C83.93 |
Non-follicular (diffuse) lymphoma, unspecified intra-abdominal lymph nodes |
C83.94 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of axilla and upper limb |
C83.95 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of inguinal region and lower limb |
C83.96 |
Non-follicular (diffuse) lymphoma, unspecified intrapelvic lymph nodes |
C83.97 |
Non-follicular (diffuse) lymphoma, unspecified spleen |
C83.98 |
Non-follicular (diffuse) lymphoma, unspecified lymph nodes of multiple sites |
C83.99 |
Non-follicular (diffuse) lymphoma, unspecified extranodal and solid organ sites |
C84.00 |
Mycosis fungoides, unspecified site |
C84.01 |
Mycosis fungoides, lymph nodes of head, face and neck |
C84.02 |
Mycosis fungoides, intrathoracic lymph nodes |
C84.03 |
Mycosis fungoides, intra-abdominal lymph nodes |
C84.04 |
Mycosis fungoides, lymph nodes of axilla and upper limb |
C84.05 |
Mycosis fungoides, lymph nodes of inguinal region and lower limb |
C84.06 |
Mycosis fungoides, intrapelvic lymph nodes |
C84.07 |
Mycosis fungoides, spleen |
C84.08 |
Mycosis fungoides, lymph nodes of multiple sites |
C84.09 |
Mycosis fungoides, extranodal and solid organ sites |
C84.10 |
Sézary disease, unspecified site |
C84.11 |
Sézary disease, lymph nodes of head, face, and neck |
C84.12 |
Sézary disease, intrathoracic lymph nodes |
C84.13 |
Sézary disease, intra-abdominal lymph nodes |
C84.14 |
Sézary disease, lymph nodes of axilla and upper limb |
C84.15 |
Sézary disease, lymph nodes of inguinal region and lower limb |
C84.16 |
Sézary disease, intrapelvic lymph nodes |
C84.17 |
Sézary disease, spleen |
C84.18 |
Sézary disease, lymph nodes of multiple sites |
C84.19 |
Sézary disease, extranodal and solid organ sites |
C84.40 |
Peripheral T-cell lymphoma, not classified, unspecified site |
C84.41 |
Peripheral T-cell lymphoma, not classified, lymph nodes of head, face and neck |
C84.42 |
Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes |
C84.43 |
Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes |
C84.44 |
Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb |
C84.45 |
Peripheral T-cell lymphoma, not classified, lymph n odes of inguinal region of lower limb |
C84.46 |
Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes |
C84.47 |
Peripheral T-cell lymphoma, not classified, spleen |
C84.48 |
Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites |
C84.49 |
Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites |
C84.60 |
Anaplastic large cell lymphoma, ALK-positive, unspecified site |
C84.61 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face and neck |
C84.62 |
Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes |
C84.63 |
Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes |
C84.64 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb |
C84.65 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb |
C84.66 |
Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes |
C84.67 |
Anaplastic large cell lymphoma, ALK-positive, spleen |
C84.68 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites |
C84.69 |
Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites |
C84.70 |
Anaplastic large cell lymphoma, ALK-negative, unspecified site |
C84.71 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face and neck |
C84.72 |
Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes |
C84.73 |
Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes |
C84.74 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb |
C84.75 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb |
C84.76 |
Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes |
C84.77 |
Anaplastic large cell lymphoma, ALK-negative, spleen |
C84.78 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites |
C84.79 |
Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites |
C84.7A |
Anaplastic large cell lymphoma, ALK-negative, breast |
C84.90 |
Mature T/NK-cell lymphomas, unspecified site |
C84.91 |
Mature T/NK-cell lymphomas, lymph nodes of head, face, and neck |
C84.92 |
Mature T/NK-cell lymphomas, intrathoracic lymph nodes |
C84.93 |
Mature T/NK-cell lymphomas, intra-abdominal lymph nodes |
C84.94 |
Mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb |
C84.95 |
Mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb |
C84.96 |
Mature T/NK-cell lymphomas, intrapelvic lymph nodes |
C84.97 |
Mature T/NK-cell lymphomas, spleen |
C84.98 |
Mature T/NK-cell lymphomas, lymph nodes of multiple sites |
C84.99 |
Mature T/NK-cell lymphomas, extranodal and solid organ sites |
C84.Z0 |
Other mature T/NK-cell lymphomas, unspecified site |
C84.Z1 |
Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck |
C84.Z2 |
Other mature T/NK-cell lymphomas, intrathoracic lymph nodes |
C84.Z3 |
Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes |
C84.Z4 |
Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb |
C84.Z5 |
Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb |
C84.Z6 |
Other mature T/NK-cell lymphomas, intrapelvic lymph nodes |
C84.Z7 |
Other mature T/NK-cell lymphomas, spleen |
C84.Z8 |
Other mature T/NK-cell lymphomas, lymph nodes of multiple sites |
C84.Z9 |
Other mature T/NK-cell lymphomas, extranodal and solid organ sites |
C85.10 |
Unspecified B-cell lymphoma unspecified site |
C85.11 |
Unspecified B-cell lymphoma lymph nodes of head, face, and neck |
C85.12 |
Unspecified B-cell lymphoma intrathoracic lymph nodes |
C85.13 |
Unspecified B-cell lymphoma intra-abdominal lymph nodes |
C85.14 |
Unspecified B-cell lymphoma lymph nodes of axilla and upper limb |
C85.15 |
Unspecified B-cell lymphoma lymph nodes of inguinal region and lower limb |
C85.16 |
Unspecified B-cell lymphoma intrapelvic lymph nodes |
C85.17 |
Unspecified B-cell lymphoma spleen |
C85.18 |
Unspecified B-cell lymphoma lymph nodes of multiple sites |
C85.19 |
Unspecified B-cell lymphoma extranodal and solid organ sites |
C85.20 |
Mediastinal (thymic) large B-cell lymphoma, unspecified site |
C85.21 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face and neck |
C85.22 |
Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes |
C85.23 |
Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes |
C85.24 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb |
C85.25 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C85.26 |
Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes |
C85.27 |
Mediastinal (thymic) large B-cell lymphoma, spleen |
C85.28 |
Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites |
C85.29 |
Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites |
C85.80 |
Other specified types of non-Hodgkin lymphoma, unspecified site |
C85.81 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face and neck |
C85.82 |
Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes |
C85.83 |
Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes |
C85.84 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C85.85 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region of lower limb |
C85.86 |
Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes |
C85.87 |
Other specified types of non-Hodgkin lymphoma, spleen |
C85.88 |
Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites |
C85.89 |
Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites |
C86.0 |
Extranodal NK/T-cell lymphoma, nasal type |
C86.1 |
Hepatosplenic T-cell lymphoma |
C86.2 |
Enteropathy-type (intestinal) T-cell lymphoma |
C86.5 |
Angioimmunoblastic T-cell lymphoma |
C86.6 |
Primary cutaneous CD30-positive T-cell proliferations |
C91.50 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission |
C91.51 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) in remission |
C91.52 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) in relapse |
D47.Z1 |
Post-transplant lymphoproliferative disorder (PTLD) |
Z85.71 |
Personal history of Hodgkin lymphoma |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |