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Avastin® (bevacizumab) (Intravenous)

Policy Number: VP-0014

Last Review Date: 09/03/2019

Date of Origin: 10/17/2008

Dates Reviewed: 06/2009, 12/2009, 03/2010, 06/2010, 09/2010, 12/2010, 02/2011, 03/2011, 06/2011, 09/2011, 12/2011, 03/2011, 06/2012, 09/2012, 12/2012, 02/2013, 03/2013, 06/2013, 08/2013, 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, 12/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019

I. Length of Authorization

Coverage will be provided for six months and may be renewed. For CNS cancers (symptom management), coverage will be provided for 12 weeks and may NOT be renewed.

II. Dosing Limits

  1. Quantity Limit (max daily dose) [Pharmacy Benefit]:
  • 100 mg/4 mL vial: 3 vials 21 days
  • 400 mg/16 mL vial: 4 vials per 21 days
  1. Max Units (per dose and over time) [Medical Benefit]:

Oncology indications (J9035):

  • 170 billable units per 21 days
  • 120 billable units per 14 days

III. Initial Approval Criteria

Coverage is provided in the following conditions:

  • Patient is 18 years or older; AND
  • Patient must have no recent history of hemorrhage or hemoptysis (the presence of blood in sputum); AND
  • Patient must not have had a surgical procedure within the preceding 28 days or have a surgical wound that has not fully healed; AND

Colorectal Cancer (CRC) †

  • Not used as part of adjuvant treatment; AND
  • Patient’s disease is metastatic, unresectable, or advanced; AND
  • Used as first-line therapy; AND
  • In combination with a fluoropyrimidine-based regimen (e.g., 5-fluorouracil/5-FU or capecitabine) ; OR
  • In combination with irinotecan or irinotecan-based regimen after previous adjuvant FOLFOX or CapeOX within the past 12 months; OR
  • Used as subsequent therapy; AND
  • In combination with a fluoropyrimidine-based regimen (e.g., 5-fluorouracil/5-FU or capecitabine) ; OR
  • In combination with irinotecan or FOLFIRI (if previously treated with oxaliplatin-based therapy without irinotecan); OR
  • In combination with FOLFOX or CapeOX (if previously treated with irinotecan-based therapy without oxaliplatin); OR
  • In combination with FOLFOX, CapeOX, irinotecan, FOLFIRI, or irinotecan and oxaliplatin (if previously treated with fluoropyrimidine-based therapy without irinotecan or oxaliplatin); OR
  • Used for metastatic disease that has progressed on first-line bevacizumab containing regimen in combination with an irinotecan and/or oxaliplatin-based regimen (if not used first-line)

Non-Squamous Non-Small Cell Lung Cancer (NSCLC) †

  • Used as first-line therapy for recurrent, locally advanced, unresectable, or metastatic disease in combination with carboplatin and paclitaxel ; OR
  • Used for recurrent, advanced, or metastatic disease (excluding locoregional recurrence or symptomatic local disease with no evidence of disseminated disease); AND
    • Used as first-line therapy for EGFR, ALK negative or unknown, PD-L1 expression ≥ 1% and PS ≤ 2 in combination with atezolizumab, carboplatin, and paclitaxel; OR
    • Used as first-line therapy in patients with PS ≤ 1 for genomic tumor aberration (e.g., EGFR, ALK, ROS1, BRAF) negative or unknown and PD-L1 < 1% or unknown OR BRAF V600E-mutation positive in combination with:
      • Carboplatin AND either paclitaxel or pemetrexed; OR
      • Cisplatin and pemetrexed; OR
      • Atezolizumab, carboplatin and paclitaxel; OR
    • Used as subsequent therapy in patients with PS ≤ 1 for genomic tumor aberration (e.g., EGFR, ALK, ROS1) positive and prior targeted therapy OR BRAF V600E-mutation positive OR PD-L1 ≥ 1% and EGFR, ALK negative or unknown with no prior platinum-doublet chemotherapy in combination with:
          •  
      • Carboplatin AND either paclitaxel or pemetrexed; OR
      • Cisplatin and pemetrexed; OR
      • Atezolizumab, carboplatin and paclitaxel; OR
    • Used as continuation maintenance therapy (bevacizumab must have been included in patient’s first-line chemotherapy regimen) for PS ≤ 2 and patient’s disease has not progressed (achieved tumor response or stable disease) after first-line systemic therapy; AND
      • Used as a single agent; OR
      • Used in combination with pemetrexed if bevacizumab was previously used with a first-line pemetrexed/platinum chemotherapy regimen; OR
      • Used in combination with atezolizumab if bevacizumab was previously used first-line as part of atezolizumab/carboplatin/paclitaxel/bevacizumab regimen

Cervical Cancer †

  • Patient’s disease must be persistent, recurrent, or metastatic; AND
  • Used in combination with paclitaxel AND either cisplatin, carboplatin, or topotecan

Breast Cancer ‡

  • Patient must have recurrent or metastatic disease; AND
  • Patient has a high tumor burden, rapidly progressive disease, or visceral crisis; AND
  • Must be used in combination with paclitaxel; AND
  • Patient must be human epidermal growth factor receptor 2 (HER2)-negative; AND
  • Disease is hormone receptor-negative; OR
  • Disease is hormone receptor-positive with visceral crisis and refractory to endocrine therapy

Renal Cell Carcinoma (RCC) †

  • Patient must have metastatic or relapsed disease; AND
  • Must be used in combination with interferon alfa ; OR
  • Must be used as a single agent in patients with non-clear cell histology ‡; OR
  • Used in combination with everolimus in patients with non-clear cell histology ; OR
  • Used in combination with erlotinib in patients with non-clear cell histology papillary disease including hereditary leiomyomatosis and renal cell cancer (HLRCC)

Central Nervous System (CNS) Cancer

  • Used for symptom management related to radiation necrosis, poorly controlled vasogenic edema, or mass effect as single-agent short-course therapy; AND
    • Patient has a diagnosis of one of the following other CNS cancers :
    • Supratentorial Astrocytoma/Oligodendroglioma (Low-Grade Infiltrative, WHO Grade II); OR
    • Primary CNS Lymphoma; OR
    • Meningiomas; OR
    • Brain, Spine, or Leptomeningeal metastases; OR
    • Medulloblastoma; OR
    • Recurrent Glioblastoma or Anaplastic Gliomas; OR
    • Recurrent Intracranial or Spinal Ependymoma (excluding subependymoma); OR
  • Used in the treatment of recurrent glioblastoma; OR
  • Used as a single agent OR in combination with one of the following: carmustine, lomustine, or temozolomide in patients with recurrent Anaplastic Gliomas ; OR
  • Used as single agent therapy for patients with progressive or recurrent disease who do not have subependymomas in patients with a diagnosis of recurrent Intracranial and Spinal Ependymoma ‡; OR
  • Used as single agent for patients with surgically inaccessible recurrent or progressive Meningioma

Ovarian Cancer †

  • Patient has malignant stage II-IV sex cord-stromal tumors ‡; AND
    • Used as single agent therapy for relapsed disease; OR
  • Patient has Epithelial or Fallopian Tube or Primary Peritoneal Cancers ; AND
    • Patient has persistent or recurrent disease; AND
  • Bevacizumab has not been used previously; AND
  • Patient is not experiencing an immediate biochemical relapse (i.e., rising CA-125 without radiographic evidence of disease); AND
    • If platinum sensitive, used in combination with carboplatin AND either gemcitabine, paclitaxel or PEGylated liposomal-doxorubicin; OR
    • If platinum resistant, used in combination with one of the following: oral cyclophosphamide, PEGylated iposomal doxorubicin, weekly paclitaxel, or topotecan †, or may be used as a single agent ‡; OR
    • Used as single agent maintenance therapy if used previously as part of combination therapy in patients with a partial or complete remission or stable disease following primary therapy or following recurrence therapy for platinum-sensitive disease; OR
    • Used as neoadjuvant therapy for endometrioid or serous histology in combination with paclitaxel and carboplatin; AND
      • Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction; OR
    • Used as primary therapy for endometrioid or serous histology in combination with paclitaxel and carboplatin; AND
    • Patient had an incomplete resection and/or has unresectable stage II-IV  residual disease; OR
    • Used as adjuvant therapy in combination with paclitaxel and carboplatin; AND
      • Patient has stage II-IV disease of serous, endometrioid, mucinous carcinoma, or clear cell carcinoma histology; OR
      • Patient has borderline epithelial tumors with invasive implants; OR
    • Used in combination with paclitaxel and carboplatin for patients with rising CA-125 levels or clinical relapse in patients with no prior chemotherapy.
      •  

Soft Tissue Sarcoma ‡

  • Used as a single agent for angiosarcoma; OR
  • Used in combination with temozolomide for solitary fibrous tumor or hemangiopericytoma 

Endometrial Carcinoma ‡

  • Used as a single agent therapy for disease that has progressed on prior cytotoxic therapy; OR
  • Used in combination with carboplatin and paclitaxel for advanced or recurrent disease

Malignant Pleural Mesothelioma ‡

  • Patient has unresectable or metastatic disease; AND
  • Must be used in combination with pemetrexed AND either cisplatin or carboplatin followed by single-agent maintenance bevacizumab

AIDS-Related Kaposi Sarcoma ‡

  • Patient has relapsed or refractory disease; AND
  • Patient has advanced cutaneous, oral, visceral, or nodal disease; AND
  • Used as subsequent therapy in combination with antiretroviral therapy (ART) after failure to two lines of systemic therapy

Vulvar Cancer

  • Used in combination with paclitaxel and cisplatin for squamous cell carcinoma; AND
  • Patient has unresectable locally advanced, metastatic, or recurrent disease

Small Bowel Adenocarcinoma

  • Used as initial therapy; AND
  • Patient has unresectable locally advanced or metastatic disease; AND
  • In combination with a fluoropyrimidine-based regimen (e.g., 5-fluorouracil/5-FU or capecitabine) in patients not appropriate for intensive therapy; OR
  • In combination with FOLFOX, CapeOX, or FOLFOXIRI in patients appropriate for intensive therapy

FDA-labeled indication(s); Compendia recommended indication(s)

Genomic Aberration Targeted Therapies (not all inclusive) §

Sensitizing EGFR mutation-positive tumors

  • Erlotinib
  • Afatinib
  • Gefitinib
  • Dacomitinib
  • Osimertinib

ALK rearrangement-positive tumors

  • Crizotinib
  • Ceritinib
  • Brigatinib
  • Alectinib

ROS1 rearrangement-positive tumors

  • Crizotinib 
  • Ceritinib

BRAF V600E-mutation positive tumors

  • Dabrafenib/Trametinib

PD-L1 expression-positive tumors (>1%)

  • Pembrolizumab
  • Atezolizumab

IV. Renewal Criteria

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet the criteria identified in section III; AND
  • Tumor response with 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: gastrointestinal perforation, surgical/wound healing complications, hemorrhage, arterial and venous thromboembolic events (ATE & VTE), uncontrolled hypertension, posterior reversible encephalopathy syndrome (PRES), nephrotic syndrome, severe infusion reactions, ovarian failure, congestive heart failure (CHF), etc.; AND

CNS Cancers – symptom management (short-course therapy):

  • May NOT be renewed

Colorectal Cancer (additional renewal opportunity):

  • Patient’s disease has progressed on a first-line bevacizumab-containing regimen; AND
  • Used in combination with an irinotecan and/or oxaliplatin-based regimen (if not used first line)

Malignant Pleural Mesothelioma – maintenance therapy:

  • Must be used as a single agent

Ovarian cancer - Platinum sensitive disease or recurrence:

  • Must be used as a single agent for maintenance therapy; OR
  • Used in combination with chemotherapy, for completion of initial therapy, up to 10 cycles total

Non-squamous non-small cell lung cancer – continuation maintenance therapy:

  • Bevacizumab must have been included in patient’s 1st line chemotherapy; AND
  • Patient must have an ECOG performance status ≤2; AND
  • Used as a single agent; OR
  • Used in combination with pemetrexed if bevacizumab was previously used with a 1st-line pemetrexed/platinum chemotherapy regimen; OR
  • Used as a single agent or in combination with atezolizumab if bevacizumab was previously used first-line as part of atezolizumab/carboplatin/paclitaxel/bevacizumab regimen

V. Dosage/Administration

Indication

Dose

CRC & Small Bowel Cancer

5 to 10 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks

NSCLC & Cervical Cancer

15 mg/kg every 3 weeks until disease progression or unacceptable toxicity.

CNS Cancers

  • For disease treatment: 10 mg/kg every 2 weeks until disease progression or unacceptable toxicity.
  • For symptom management: 5-10 mg/kg every 2 weeks up to 12 weeks duration

RCC

10 mg/kg every 2 weeks until disease progression or unacceptable toxicity.

MPM

15 mg/kg every 3 weeks in combination with chemotherapy for up to 6 cycles followed by single agent use, at the same dose/frequency, until disease progression or unacceptable toxicity.

Ovarian Cancer

Platinum-sensitive:

15 mg/kg every 3 weeks for up to 8 cycles when used with paclitaxel or up to 10 cycles when used with gemcitabine; followed by single-agent bevacizumab 15 mg/kg IV every 3 weeks until disease progression or unacceptable toxicity

Platinum-resistant:

10 mg/kg every 2 weeks or 15 mg/kg every 3 weeks until disease progression or unacceptable toxicity

All Other Oncology Indications

5-10 mg/kg every 2 weeks OR 7.5-15 mg/kg every 3 weeks

VI. Billing Code/Availability Information

Jcode:

  • J9035 – Injection, bevacizumab, 10 mg; 1 billable unit = 10 mg

NDC:

  • Avastin single-use vial, 100 mg/4 mL solution for injection: 50242-0060-xx
  • Avastin single-use vial, 400 mg/16 mL solution for injection: 50242-0061-xx

VII. References

  1. Avastin [package insert]. South San Francisco, CA; Genentech; February 2019. Accessed July 2019.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) bevacizumab. National Comprehensive Cancer Network, 2019. 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 2019.
  3. Ceresoli GL, Zucali PA, Mencoboni M, et al. Phase II study of pemetrexed and carboplatin plus bevacizumab as first-line therapy in malignant pleural mesothelioma. Br J Cancer. 2013 Aug 6; 109(3): 552–558
  4. Delishaj D, Ursino S, Pasqualetti F, et al. Bevacizumab for the Treatment of Radiation-Induced Cerebral Necrosis: A Systematic Review of the Literature. J Clin Med Res. 2017 Apr; 9(4): 273–280.
  5. National Government Services, Inc. Local Coverage Article for BEVACIZUMAB (e.g., Avastin™) - Related to LCD L33394 (A52370). Centers for Medicare & Medicaid Services, Inc. Updated on 01/24/2019 with effective date 02/01/2019. Accessed July 2019.
  6. CGS Administrators, LLC. Local Coverage Article for Billing and Coding Bevacizumab: Avastin (A56604). Centers for Medicare & Medicaid Services, Inc. Updated on 05/22/2019 with effective dates 05/16/2019. Accessed July 2019.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

C17.0

Malignant neoplasm duodenum

C17.1

Malignant neoplasm jejunum

C17.2

Malignant neoplasm ileum

 C17.3  Meckel's diverticulum, malignant  

C17.8

Malignant neoplasm of overlapping sites of small intestines

C17.9

Malignant neoplasm of small intestine, unspecified

C18.0

Malignant neoplasm of cecum

C18.1

Malignant neoplasm of appendix

C18.2

Malignant neoplasm of ascending colon

C18.3

Malignant neoplasm of hepatic flexure

C18.4

Malignant neoplasm of transverse colon

C18.5

Malignant neoplasm of splenic flexure

C18.6

Malignant neoplasm of descending colon

C18.7

Malignant neoplasm of sigmoid colon

C18.8

Malignant neoplasm of overlapping sites of large intestines

C18.9

Malignant neoplasm of colon, unspecified

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.8

Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C33

Malignant neoplasm of trachea

C34.00

Malignant neoplasm of unspecified main bronchus

C34.01

Malignant neoplasm of right main bronchus

C34.02

Malignant neoplasm of left main bronchus

C34.10

Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11

Malignant neoplasm of upper lobe, right bronchus or lung

C34.12

Malignant neoplasm of upper lobe, left bronchus or lung

C34.2

Malignant neoplasm of middle lobe, bronchus or lung

C34.30

Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31

Malignant neoplasm of lower lobe, right bronchus or lung

C34.32

Malignant neoplasm of lower lobe, left bronchus or lung

C34.80

Malignant neoplasm of overlapping sites of unspecified bronchus or lung

C34.81

Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82

Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90

Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91

Malignant neoplasm of unspecified part of right bronchus or lung

C34.92

Malignant neoplasm of unspecified part of left bronchus or lung

C38.4

Malignant neoplasm of pleura

C45.0

Mesothelioma of pleura

C45.1

Mesothelioma of peritoneum

C46.0

Kaposi's sarcoma of skin

C46.1

Kaposi's sarcoma of soft tissue

C46.2

Kaposi's sarcoma of palate

C46.3

Kaposi's sarcoma of lymph nodes

C46.4

Kaposi's sarcoma of gastrointestinal sites

C46.50

Kaposi's sarcoma of unspecified lung

C46.51

Kaposi's sarcoma of right lung

C46.52

Kaposi's sarcoma of left lung

C46.7

Kaposi's sarcoma of other sites

C46.9

Kaposi's sarcoma, unspecified

C48.0

Malignant neoplasm of retroperitoneum

C48.1

Malignant neoplasm of specified parts of peritoneum

C48.2

Malignant neoplasm of peritoneum, unspecified

C48.8

Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum

C49.0

Malignant neoplasm of connective and soft tissue of head, face and neck

C49.10

Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder

C49.11

Malignant neoplasm of connective and soft tissue of right upper limb including shoulder

C49.12

Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder

C49.20

Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip

C49.21

Malignant neoplasm of connective and soft tissue of right lower limb, including hip

C49.22

Malignant neoplasm of connective and soft tissue of left lower limb, including hip

C49.3

Malignant neoplasm of connective and soft tissue of thorax

C49.4

Malignant neoplasm of connective and soft tissue of abdomen

C49.5

Malignant neoplasm of connective and soft tissue of pelvis

C49.6

Malignant neoplasm of connective and soft tissue of trunk, unspecified

C49.8

Malignant neoplasm of overlapping sites of connective and soft tissue

C49.9

Malignant neoplasm of connective and soft tissue, unspecified

C50.011

Malignant neoplasm of nipple and areola, right female breast

C50.012

Malignant neoplasm of nipple and areola, left female breast

C50.019

Malignant neoplasm of nipple and areola, unspecified female breast

C50.021

Malignant neoplasm of nipple and areola, right male breast

C50.022

Malignant neoplasm of nipple and areola, left male breast

C50.029

Malignant neoplasm of nipple and areola , unspecified male breast

C50.111

Malignant neoplasm of central portion of right female breast

C50.112

Malignant neoplasm of central portion of left female breast

C50.119

Malignant neoplasm of central portion of unspecified female breast

C50.121

Malignant neoplasm of central portion of right male breast

C50.122

Malignant neoplasm of central portion of left male breast

C50.129

Malignant neoplasm of central portion of unspecified male breast

C50.211

Malignant neoplasm of upper-inner quadrant of right female breast

C50.212

Malignant neoplasm of upper-inner quadrant of left female breast

C50.219

Malignant neoplasm of upper-inner quadrant of unspecified  female breast

C50.221

Malignant neoplasm of upper-inner quadrant of right male breast

C50.222

Malignant neoplasm of upper-inner quadrant of left male breast

C50.229

Malignant neoplasm of upper-inner quadrant of unspecified male breast

C50.311

Malignant neoplasm of lower-inner quadrant of right female breast

C50.312

Malignant neoplasm of lower-inner quadrant of left female breast

C50.319

Malignant neoplasm of lower-inner quadrant of unspecified female breast

C50.321

Malignant neoplasm of lower-inner quadrant of right male breast

C50.322

Malignant neoplasm of lower-inner quadrant of left male breast

C50.329

Malignant neoplasm of lower-inner quadrant of unspecified male breast

C50.411

Malignant neoplasm of upper-outer quadrant of right female breast

C50.412

Malignant neoplasm of upper-outer quadrant of left female breast

C50.419

Malignant neoplasm of upper-outer quadrant of unspecified female breast

C50.421

Malignant neoplasm of upper-outer quadrant of right male breast

C50.422

Malignant neoplasm of upper-outer quadrant of left male breast

C50.429

Malignant neoplasm of upper-outer quadrant of unspecified male breast

C50.511

Malignant neoplasm of lower-outer quadrant of right female breast

C50.512

Malignant neoplasm of lower-outer quadrant of left female breast

C50.519

Malignant neoplasm of lower-outer quadrant of unspecified female breast

C50.521

Malignant neoplasm of lower-outer quadrant of right male breast

C50.522

Malignant neoplasm of lower-outer quadrant of left male breast

C50.529

Malignant neoplasm of lower-outer quadrant of unspecified male breast

C50.611

Malignant neoplasm of axillary tail of right female breast

C50.612

Malignant neoplasm of axillary tail of left female breast

C50.619

Malignant neoplasm of axillary tail of unspecified female breast

C50.621

Malignant neoplasm of axillary tail of right male breast

C50.622

Malignant neoplasm of axillary tail of left male breast

C50.629

Malignant neoplasm of axillary tail of unspecified male breast

C50.811

Malignant neoplasm of overlapping sites of right female breast

C50.812

Malignant neoplasm of overlapping sites of left female breast

C50.819

Malignant neoplasm of overlapping sites of unspecified female breast

C50.821

Malignant neoplasm of overlapping sites of right male breast

C50.822

Malignant neoplasm of overlapping sites of left male breast

C50.829

Malignant neoplasm of overlapping sites of unspecified male breast

C50.911

Malignant neoplasm of unspecified site of right female breast

C50.912

Malignant neoplasm of unspecified site of left female breast

C50.919

Malignant neoplasm of unspecified site of unspecified female breast

C50.921

Malignant neoplasm of unspecified site of right male breast

C50.922

Malignant neoplasm of unspecified site of left male breast

C50.929

Malignant neoplasm of unspecified site of unspecified male breast

C51.0

Malignant neoplasm of labium majus

C51.1

Malignant neoplasm of labium minus

C51.2

Malignant neoplasm of clitoris

C51.8

Malignant neoplasm of overlapping sites of vulva

C51.9

Malignant neoplasm of vulva, unspecified

C53.0

Malignant neoplasm of endocervix

C53.1

Malignant neoplasm of exocervix

C53.8

Malignant neoplasm of overlapping sites of cervix uteri

C53.9

Malignant neoplasm of cervix uteri, unspecified

C54.0

Malignant neoplasm of isthmus uteri

C54.1

Malignant neoplasm of endometrium

C54.2

Malignant neoplasm of myometrium

C54.3

Malignant neoplasm of fundus uteri

C54.8

Malignant neoplasm of overlapping sites of corpus uteri

C54.9

Malignant neoplasm of corpus uteri, unspecified

C55

Malignant neoplasm of uterus, part unspecified

C56.1

Malignant neoplasm of right ovary

C56.2

Malignant neoplasm of left ovary

C56.9

Malignant neoplasm of unspecified ovary

C57.00

Malignant neoplasm of unspecified fallopian tube

C57.01

Malignant neoplasm of right fallopian tube

C57.02

Malignant neoplasm of left fallopian tube

C57.10

Malignant neoplasm of unspecified broad ligament

C57.11

Malignant neoplasm of right broad ligament

C57.12

Malignant neoplasm of left broad ligament

C57.20

Malignant neoplasm of unspecified round ligament

C57.21

Malignant neoplasm of right round ligament

C57.22

Malignant neoplasm of left round ligament

C57.3

Malignant neoplasm of parametrium

C57.4

Malignant neoplasm of uterine adnexa, unspecified

C57.7

Malignant neoplasm of other specified female genital organs

C57.8

Malignant neoplasm of overlapping sites of female genital organs

C57.9

Malignant neoplasm of female genital organ, unspecified

C64.1

Malignant neoplasm of right kidney, except renal pelvis

C64.2

Malignant neoplasm of left kidney, except renal pelvis

C64.9

Malignant neoplasm of unspecified kidney, except renal pelvis

C65.1

Malignant neoplasm of right renal pelvis

C65.2

Malignant neoplasm of left renal pelvis

C65.9

Malignant neoplasm of unspecified renal pelvis

C70.0

Malignant neoplasm of cerebral meninges

C70.1

Malignant neoplasm of spinal meninges

C70.9

Malignant neoplasm of meninges, unspecified

C71.0

Malignant neoplasm of cerebrum, except lobes and ventricles

C71.1

Malignant neoplasm of frontal lobe

C71.2

Malignant neoplasm of temporal lobe

C71.3

Malignant neoplasm of parietal lobe

C71.4

Malignant neoplasm of occipital lobe

C71.5

Malignant neoplasm of cerebral ventricle

C71.6

Malignant neoplasm of cerebellum

C71.7

Malignant neoplasm of brain stem

C71.8

Malignant neoplasm of overlapping sites of brain

C71.9

Malignant neoplasm of brain, unspecified

C72.0

Malignant neoplasm of spinal cord

C72.9

Malignant neoplasm of central nervous system, unspecified

C78.00

Secondary malignant neoplasm of unspecified lung

C78.01

Secondary malignant neoplasm of right lung

C78.02

Secondary malignant neoplasm of left lung

C78.6

Secondary malignant neoplasm of retroperitoneum and peritoneum

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

C79.31

Secondary malignant neoplasm of brain

C79.32

Secondary malignant neoplasm of cerebral meninges

C79.82

Secondary malignant neoplasm of genital organs

C79.89

Secondary malignant neoplasm of other specified sites

C79.9

Secondary malignant neoplasm of unspecified site

C83.30

Diffuse large B-cell lymphoma unspecified site

C83.31

Diffuse large B-cell lymphoma lymph nodes of head, face, and neck

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

C83.89

Other non-follicular lymphoma extranodal and solid organ sites

C85.89

Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites

D32.0

Benign neoplasm of cerebral meninges

D32.1

Benign neoplasm of spinal meninges

D32.9

Benign neoplasm of meninges, unspecified

D42.0

Neoplasm of uncertain behavior of cerebral meninges

D42.1

Neoplasm of uncertain behavior of spinal meninges

D42.9

Neoplasm of uncertain behavior of meninges, unspecified

D43.0

Neoplasm of uncertain behavior of brain, supratentorial

D43.1

Neoplasm of uncertain behavior of brain, infratentorial

D43.2

Neoplasm of uncertain behavior of brain, unspecified

D43.4

Neoplasm of uncertain behavior of spinal cord

I67.89

Other cerebrovascular disease

Z85.038

Personal history of other malignant neoplasm of large intestine

Z85.068

Personal history of other malignant neoplasm of small intestine

Z85.118

Personal history of other malignant neoplasm of bronchus and lung

Z85.3

Personal history of malignant neoplasm of breast

Z85.43

Personal history of malignant neoplasm of ovary

Z85.528

Personal history of other malignant neoplasm of kidney

Z85.831

Personal history of malignant neoplasm of soft tissue

Z85.841

Personal history of malignant neoplasm of brain

Z85.848

Personal history of malignant neoplasm of other parts of nervous tissue

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

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 Determination (NCD) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD):

Jurisdiction(s): 6, K

NCD/LCD Document (s): A52370

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A52370&bc=gAAAAAAAAAAAAA== 

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, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

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