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Bevacizumab: Avastin®; Mvasi®; Zirabev™; Alymsys®; Vegzelma® *ONCOLOGY*
Policy Number: VP-0014
(Intravenous) *ONCOLOGY*
Last Review Date: 06/04/2024
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, 12/2019, 03/2020, 06/2020, 09/2020, 12/2020, 03/2021, 06/2021, 09/2021, 12/2021, 03/2022, 05/2022, 09/2022, 11/2022, 03/2023, 06/2023, 09/2023, 12/2023, 01/2024, 03/2024, 06/2024
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. |
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Length of Authorization 9
Coverage will be provided for 6 months and may be renewed (unless otherwise specified).
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Adult CNS Cancers (symptom management): Coverage will be provided for twelve (12) weeks and may NOT be renewed.
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Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
Avastin, Mvasi, Zirabev, Alymsys, Vegzelma, Avzivi:
- 100 mg/4 mL single-dose vial: 3 vials 21 days
- 400 mg/16 mL single-dose vial: 4 vials per 21 days
- Max Units (per dose and over time) [HCPCS Unit]:
Oncology indications (J9035/Q5107/Q5118/Q5126/Q5129):
- CRC & Appendiceal Adenocarcinoma, CNS Cancers, RCC:
- 120 billable units per 14 days
- Small Bowel Adenocarcinoma & Ampullary Adenocarcinoma:
- 90 billable units per 14 days
- NSCLC, Cervical Cancer, HCC, Vaginal Cancer, Vulvar Cancer, & Mesotheliomas:
- 170 billable units per 21 days
- All other indications:
- 170 billable units per 14 days
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Initial Approval Criteria 1-6
Coverage is provided in the following conditions:
For PEEHIP Members Only |
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For Commercial Members Only |
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Patient is at least 18 years of age, unless otherwise specified; AND
Universal Criteria 1-6
- Patient has no recent history of hemoptysis (i.e., the presence of ≥2.5 mL 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
Ampullary Adenocarcinoma ‡ 7
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen for intestinal type disease; AND
- Used as first-line therapy for unresectable localized or metastatic disease; OR
- Used for disease progression
Adult Central Nervous System (CNS) Cancers † ‡ Ф 1-7,9,28,29
- Used as single-agent short-course therapy for symptom management related to radiation necrosis, poorly controlled vasogenic edema, or mass effect; AND
- Patient has a diagnosis of one of the following CNS cancers ‡:
- Circumscribed Glioma
- Primary CNS Lymphoma
- Meningiomas
- Brain or Spine metastasesMedulloblastoma
- Glioblastoma/Gliosarcoma/H3-mutated high-grade glioma
- IDH-mutant Astrocytoma (WHO Grade 2-4)
- IDH-mutant, 1p19q codeleted Oligodendroglioma (WHO Grade 2 or 3)
- Intracranial or Spinal Ependymoma (excluding subependymoma); OR
- Used for recurrent or progressive disease; AND
- Patient has a diagnosis of one of the following CNS cancers:
- IDH-mutant, 1p19q codeleted Oligodendroglioma (WHO Grade 3) ‡
- Glioblastoma/Gliosarcoma/H3-mutated high-grade glioma † ‡
- IDH-mutant Astrocytoma (WHO Grade 3 or 4) ‡; AND
- Used as a single agent; OR
- Used in combination with carmustine, lomustine, or temozolomide; AND
- Patient has failed bevacizumab monotherapy; OR
- Patient has a diagnosis of one of the following CNS cancers:
- Used as a single agent for Intracranial or Spinal Ependymoma (excluding subependymoma) after prior radiation therapy ‡; OR
- Used as a single agent for surgically inaccessible Meningiomas when radiation is not possible ‡
Cervical Cancer † ‡ 1-7,31,50,61
- Patient has persistent, recurrent, or metastatic disease; AND
- Disease has adenocarcinoma, adenosquamous, or squamous cell carcinoma histology; AND
- Used in combination with paclitaxel AND either cisplatin, carboplatin, or topotecan^; OR
- Used in combination with pembrolizumab, paclitaxel, AND cisplatin or carboplatin^; AND
- Tumor expresses PD-L1 (Combined Positive Score [CPS] ≥1) as determined by an FDA-approved or CLIA compliant testv; OR
- Used as a single agent as subsequent therapy; OR
- Patient has small cell neuroendocrine carcinoma of the cervix (NECC); AND
- Used in combination with paclitaxel and topotecan^; AND
- Used as first-line therapy; OR
- Used as subsequent therapy (if not previously used as first-line); OR
- Used as a single agent as subsequent therapy
- Used in combination with paclitaxel and topotecan^; AND
- Disease has adenocarcinoma, adenosquamous, or squamous cell carcinoma histology; AND
^ Bevacizumab may be continued as a maintenance therapy
Colorectal Cancer (CRC) † ‡ 1-7,20-25,51
- Will not be used as part of adjuvant treatment; AND
- Used in combination with intravenous fluorouracil-based chemotherapy as first- or second-line treatment for metastatic disease †; OR
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen as first-line or subsequent therapy for metastatic, unresectable (or medically inoperable), or advanced disease; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy; OR
- Used in combination with irinotecan as initial treatment for unresectable metastatic disease;
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; AND
- Patient received previous FOLFOX or CapeOX within the past 12 months; OR
- Used in combination irinotecan as subsequent therapy for advanced or metastatic disease; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy; OR
- Used in combination with a fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based regimen (not used first line) as second-line therapy for metastatic disease that has progressed on a first-line bevacizumab-containing regimen †; OR
- Used in combination with trifluridine and tipiracil as subsequent therapy for advanced or metastatic disease; AND
- Patient progressed through all available regimens (e.g., oxaliplatin-based therapy, irinotecan-based therapy, fluoropyrimidine-based therapy, etc.)*; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy; OR
- Patient progressed through all available regimens (e.g., oxaliplatin-based therapy, irinotecan-based therapy, fluoropyrimidine-based therapy, etc.)*; AND
- Used as primary treatment for T3, N Any; T1-2, N1-2; T4, N Any rectal cancer; AND
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen; AND
- Used if resection is contraindicated following total neoadjuvant therapy; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy; OR
- Used if resection is contraindicated following neoadjuvant/definitive immunotherapy; AND
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease
- Used if resection is contraindicated following total neoadjuvant therapy; AND
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen; AND
*Refer to NCCN Colon and Rectal Cancer guidelines for regimens.
Appendiceal Adenocarcinoma – Colon Cancer ‡ 7,48
- Used as initial therapy for advanced or metastatic disease; AND
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy; OR
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen; AND
- Used as subsequent therapy for progression of advanced or metastatic disease; AND
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) or irinotecan-based regimen following previous oxaliplatin-, irinotecan-, and/or fluoropyrimidine-based therapy; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Used in combination with trifluridine and tipiracil; AND
- Patient progressed through all available regimens (e.g., oxaliplatin-based therapy, irinotecan-based therapy, therapy without irinotecan or oxaliplatin, etc.)*; AND
- Patient has proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease; OR
- Patient has deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease or polymerase epsilon/delta (POLE/POLD1) mutation; AND
- Patient is not eligible for or has progressed on checkpoint inhibitor immunotherapy
- Patient progressed through all available regimens (e.g., oxaliplatin-based therapy, irinotecan-based therapy, therapy without irinotecan or oxaliplatin, etc.)*; AND
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) or irinotecan-based regimen following previous oxaliplatin-, irinotecan-, and/or fluoropyrimidine-based therapy; AND
*Refer to NCCN Colon Cancer guidelines for regimens.
Endometrial Carcinoma (Uterine Neoplasms) ‡ 7,38
- Patient has recurrent disease; AND
- Used as a single agent; AND
- Used as subsequent therapy for disease that has progressed on prior cytotoxic chemotherapy; OR
- Used as continuation maintenance therapy following use in combination with carboplatin and paclitaxel; OR
- Used in combination with carboplatin and paclitaxel; AND
- Used as first-line therapy (excluding use for isolated metastases); OR
- Used as subsequent therapy
- Used as a single agent; AND
Hepatocellular Carcinoma (HCC) † ‡ Ф 1,7,17,18,55
- Used in combination with atezolizumab; AND
- Used as first-line therapy for unresectable or metastatic disease †; OR
- Used as adjuvant therapy following resection or ablation; AND
- Patient is at high risk of recurrence (defined as size > 5cm, > 3 tumors, macrovascular invasion or microvessel invasion on histology or grade 3/4 histology)
Peritoneal* Mesothelioma (PeM) ‡ 7,45,52
- Used as adjuvant therapy; AND
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Patient has unicavitary disease with epithelioid histology; AND
- Patient has surgical/pathologic high-risk features** and no neoadjuvant therapy was given; OR
- Used as first-line therapy; AND
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Patient has biphasic/sarcomatoid histology or bicavitary disease; OR
- Patient has unicavitary disease with epithelioid histology; AND
- Patient is medically inoperable and/or complete cytoreduction is not achievable (including high-risk features**); OR
- Patient has recurrent disease after prior cytoreductive surgery (CRS) + hyperthermic intraperitoneal (IP) chemotherapy (HIPEC) and no previous adjuvant systemic therapy was given; OR
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Used as subsequent therapy; AND
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Immunotherapy was administered as first-line treatment; OR
- Used as a rechallenge if pemetrexed-based treatment was administered first-line with good response; OR
- Used in combination with atezolizumab; AND
- Patient has not received previous therapy with immune checkpoint inhibitors (e.g., nivolumab, pembrolizumab, durvalumab, avelumab, cemiplimab, dostarlimab, nivolumab/relatlimab, retifanlimab, toripalimab, etc.)
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
*Note: May also be used for pericardial mesothelioma and tunica vaginalis testis mesothelioma.
** High-risk features include Ki-67 >9%, nodal metastasis, high tumor burden (Peritoneal Cancer Index [PCI] >17), completeness of cytoreduction (CC) score >1, biphasic disease, or bicavitary disease.
Pleural* Mesothelioma (PM) ‡ 7,40,52
- Used as first-line therapy; AND
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Patient has clinical stage I–IIIA disease with epithelioid histology; OR
- Patient has clinical stage IIIB or IV disease, sarcomatoid or biphasic histology, or medically inoperable disease; OR
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Used as subsequent therapy; AND
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
- Immunotherapy was administered as first-line treatment; OR
- Used as a rechallenge if pemetrexed-based treatment was administered first-line with good response
- Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
*Note: May also be used for pericardial mesothelioma and tunica vaginalis testis mesothelioma.
Non-Squamous Non-Small Cell Lung Cancer (NSCLC) † ‡ 1-7,13,15,16,26,27
- Used for recurrent, advanced, or metastatic disease (excluding locoregional recurrence or symptomatic local disease with no evidence of disseminated disease) or mediastinal lymph node recurrence with prior radiation therapy; AND
- Used as first-line therapy; AND
- Used in combination with erlotinib for EGFR exon 19 deletion or exon 21 L858R mutations; OR
- Used in combination with carboplatin and paclitaxel †; OR
- Used for one of the following:
- Patients with a performance status (PS) 0-1 who have tumors that are negative for actionable molecular biomarkers* (may be KRAS G12C mutation positive) and PD-L1 expression < 1%
- PD-L1 expression positive (PD-L1 ≥ 1%) tumors that are negative for actionable molecular biomarkers* (may be KRAS G12C mutation positive)
- Patients with a PS 0-1 who are positive for one of the following molecular biomarkers: EGFR exon 20, BRAF V600E, NTRK1/2/3 gene fusion, MET exon 14 skipping, RET rearrangement, or ERBB2 (HER2); AND
- Used in combination with one of the following:
- Pemetrexed AND either carboplatin or cisplatin in patients with contraindications¥ to PD-1 or PD-L1 inhibitors
- Atezolizumab, carboplatin, and paclitaxel; OR
- Used as subsequent therapy in patients with a PS 0-1; AND
- Used for one of the following:
- EGFR exon 19 deletion or exon 21 L858R mutation, EGFR S768I, L861Q, and/or G719X mutation, ALK rearrangement, or ROS1 rearrangement positive tumors AND patient received prior targeted therapy§ for those aberrations
- BRAF V600E mutation, NTRK1/2/3 gene fusion, MET exon 14 skipping mutation, or RET rearrangement positive tumors
- PD-L1 expression positive (PD-L1 ≥ 1%) tumors that are negative for actionable molecular biomarkers* after prior PD-1/PD-L1 inhibitor therapy but no prior platinum-containing chemotherapy; AND
- Used in combination with one of the following:
- Carboplatin and paclitaxel in patients with contraindications¥ to PD-1 or PD-L1 inhibitors
- Pemetrexed AND either carboplatin or cisplatin in patients with contraindications¥ to PD-1 or PD-L1 inhibitors
- Atezolizumab, carboplatin, and paclitaxel (excluding use in patients who have received prior PD-1/PD-L1 inhibitor therapy); OR
- Used for one of the following:
- Used as continuation maintenance therapy in patients who achieved a tumor response or stable disease after first-line systemic therapy; AND
- Used as a single agent (bevacizumab must have been included in the first-line regimen); OR
- Used in combination with pemetrexed following a first-line bevacizumab/pemetrexed/platinum chemotherapy regimen; OR
- Used in combination with atezolizumab following a first-line atezolizumab/carboplatin/paclitaxel/bevacizumab regimen; OR
- Used as continuation of therapy following disease progression on erlotinib with bevacizumab; AND
- Patient has asymptomatic disease, symptomatic brain lesions, or symptomatic systemic limited progression; AND
- Patient has T790M negative disease
- Used as first-line therapy; AND
*Note: Actionable molecular genomic biomarkers include EGFR, KRAS, ALK, ROS1, BRAF, NTRK1/2/3, MET, RET, and ERBB2 (HER2). Complete genotyping for EGFR, KRAS, ALK, ROS1, BRAF, NTRK1/2/3, MET, RET, and ERBB2 (HER2), via biopsy and/or plasma testing. If a clinically actionable marker is found, it is reasonable to start therapy based on the identified marker. Treatment is guided by available results and, if unknown, these patients are treated as though they do not have driver oncogenes. |
¥ Note: Contraindications for treatment with PD-1/PD-L1 inhibitors may include active or previously documented autoimmune disease and/or current use of immunosuppressive agents, and some oncogenic drivers (i.e., EGFR exon 19 deletion or exon 21 L858R, ALK rearrangements) have been shown to be associated with less benefit from PD-1/PD-L1 inhibitors. |
Ovarian, Fallopian Tube, and Primary Peritoneal Cancer † ‡ Ф 1-7,14,32-35,53
- Patient has malignant stage II-IV sex cord-stromal tumors ‡; AND
- Used as a single agent for clinically relapsed disease; OR
- Patient has epithelial* ovarian, fallopian tube, or primary peritoneal cancer †; AND
- Patient has persistent or recurrent disease; AND
- Patient is not experiencing an immediate biochemical relapse (i.e., rising CA-125 without radiographic evidence of disease); AND
- Patient has platinum-sensitive disease; AND
- Used as a single agent; OR
- Used in combination with carboplatin AND either gemcitabine, paclitaxel † or liposomal doxorubicin; OR
- Patient has platinum-resistant disease; AND
- Used as a single agent; OR
- Used in combination with one of the following: oral cyclophosphamide, gemcitabine, liposomal doxorubicin, paclitaxel, or topotecan; OR
- Used in combination with oral cyclophosphamide and pembrolizumab; OR
- Used in combination with mirvetuximab soravtansine-gynx (in folate receptor-alpha expressing tumors); OR
- Used in combination with carboplatin AND either gemcitabine, paclitaxel or liposomal doxorubicin; OR
- Used in combination with paclitaxel and carboplatin for rising CA-125 levels or clinical relapse in patients who have received no prior chemotherapy (mucinous, clear cell, carcinosarcoma, endometrioid, and high-grade serous histology only); OR
- Patient has platinum-sensitive disease; AND
- Patient is not experiencing an immediate biochemical relapse (i.e., rising CA-125 without radiographic evidence of disease); AND
- Used in combination with paclitaxel and carboplatin for recurrence in patients who have received no prior chemotherapy (low-grade serous histology only); OR
- Used as maintenance therapy; AND
- Used for stage II-IV disease following primary therapy including bevacizumab; AND
- Used as a single agent in patients that are BRCA1/2 wild-type or unknown AND homologous recombination (HR) proficient, HR deficient, or status unknown (grade 2/3 endometrioid and high-grade serous histology only); OR
- Used in combination with olaparib or niraparib (if unable to tolerate olaparib); AND
- Patient is BRCA1/2 wild-type or unknown AND HR deficient (grade 2/3 endometrioid and high-grade serous histology only); OR
- Patient has a germline or somatic BRCA1/2 mutation (grade 2/3 endometrioid, high-grade serous, clear cell, carcinosarcoma histology only); OR
- Used as a single agent following recurrence therapy with chemotherapy plus bevacizumab for platinum-sensitive disease; OR
- Used as continued treatment for stable disease following neoadjuvant therapy (endometrioid and serous histology only); AND
- Used in combination with carboplatin AND paclitaxel or docetaxel; OR
- Used in combination with oxaliplatin and docetaxel; OR
- Used for stage II-IV disease following primary therapy including bevacizumab; AND
- Used as neoadjuvant therapy (endometrioid and serous histology only); AND
- Used in combination with one of the following:
- Carboplatin AND paclitaxel or docetaxel
- Oxaliplatin and docetaxel; AND
- Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction; OR
- Used in combination with one of the following:
- Used as adjuvant therapy; AND
- Used in combination with oxaliplatin and docetaxel; AND
- Patient has pathologic stage II-IV disease (mucinous, clear cell, carcinosarcoma, grade 2/3 endometrioid, and high-grade serous histology only); OR
- Used following interval debulking surgery (IDS) in patients with a response or stable disease to neoadjuvant therapy (endometrioid and serous histology only); AND
- Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction; OR
- Used in combination with carboplatin AND paclitaxel or docetaxel; AND
- Patient has pathologic stage II-IV disease; OR
- Used following interval debulking surgery (IDS) in patients with a response or stable disease to neoadjuvant therapy (endometrioid and serous histology only); AND
- Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction
- Used in combination with oxaliplatin and docetaxel; AND
- Patient has persistent or recurrent disease; AND
*Epithelial subtypes include serous, endometrioid, carcinosarcoma (malignant mixed Müllerian tumors [MMMTs] of the ovary), clear cell, mucinous, and borderline epithelial tumors (also known as low malignant potential [LMP] tumors).
Pediatric Central Nervous System (CNS) Cancers ‡ 7,47,56-60
- Patient is ≤ 18 years of age; AND
- Patient has recurrent or progressive disease; AND
- Patient has diffuse high-grade glioma (excluding oligodendroglioma, IDH-mutant and 1p/19q co-deleted or astrocytoma IDH-mutant); AND
- Used as a single agent for palliation; OR
- Patient has medulloblastoma; AND
- Used as part of the TEMR regimen (temozolomide, irinotecan, bevacizumab); OR
- Used as part of MEMMAT regimen (thalomide, celecoximb, fenofibrate, etoposide, cyclophosphamide, bevacizumab)
- Patient has diffuse high-grade glioma (excluding oligodendroglioma, IDH-mutant and 1p/19q co-deleted or astrocytoma IDH-mutant); AND
Renal Cell Carcinoma (RCC) † ‡ Ф 1-7,30
- Used in combination with interferon alfa for metastatic disease †; OR
- Patient has relapsed or metastatic disease with non-clear cell histology ‡; AND
- Used as a single agent; OR
- Used in combination with everolimus ; OR
- Used in combination with erlotinib for advanced papillary disease including hereditary leiomyomatosis and renal cell carcinoma (HLRCC)-associated RCC
Small Bowel Adenocarcinoma ‡ 7,19
- Patient has advanced or metastatic disease; AND
- Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen
Soft Tissue Sarcoma ‡ 7,37,42
- Used as a single agent for angiosarcoma; OR
- Used in combination with temozolomide for solitary fibrous tumor
Vaginal Cancer ‡ 7,31,61
- Patient has recurrent or metastatic disease; AND
- Used in combination with paclitaxel AND either cisplatin, carboplatin, or topotecan; AND
- Used as first-line therapy; OR
- Used as subsequent therapy (if not previously used as first-line); OR
- Used in combination with pembrolizumab, paclitaxel, AND either cisplatin or carboplatin; AND
- Tumor expresses PD-L1 (Combined Positive Score [CPS] ≥1) as determined by an FDA-approved or CLIA compliant testv; AND
- Used as first-line therapy; OR
- Used as subsequent therapy (if not previously used as first-line); OR
- Tumor expresses PD-L1 (Combined Positive Score [CPS] ≥1) as determined by an FDA-approved or CLIA compliant testv; AND
- Used as a single agent; AND
- Used as subsequent therapy
- Used in combination with paclitaxel AND either cisplatin, carboplatin, or topotecan; AND
Vulvar Cancer ‡ 7,31
- Used in combination with paclitaxel and cisplatin; AND
- Patient has advanced, recurrent, or metastatic disease; AND
- Used as first-line therapy; OR
- Used as subsequent therapy (if not previously used)
v If confirmed using an FDA-approved assay – http://www.fda.gov/companiondiagnostics
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
§ Genomic Aberration/Mutational Driver Targeted Therapies (Note: not all inclusive, refer to guidelines for appropriate use) |
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EGFR exon 19 deletion or exon 21 L858R tumors |
EGFR S768I, L861Q, and/or G719X mutation positive tumors |
EGFR exon 20 insertion mutation positive tumors |
NTRK1/2/3 gene fusion positive tumors |
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ALK rearrangement-positive tumors |
ROS1 rearrangement-positive tumors |
BRAF V600E-mutation positive tumors |
ERBB2 (HER2) mutation positive tumors |
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PD-L1 tumor expression ≥ 1% |
MET exon-14 skipping mutations |
RET rearrangement-positive tumors |
KRAS G12C mutation positive tumors |
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Renewal Criteria 1-7,9
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 as 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: gastrointestinal perforations and fistulae, surgical/wound healing complications, necrotizing fasciitis, hemorrhage, arterial and venous thromboembolic events (ATE & VTE), uncontrolled hypertension, posterior reversible encephalopathy syndrome (PRES), nephrotic syndrome, proteinuria, severe infusion-related reactions, ovarian failure, congestive heart failure (CHF), etc.; AND
Adult CNS Cancers – symptom management (short-course therapy):
- Coverage may NOT be renewed
Adult CNS Cancers (in combination with carmustine, lomustine, or temozolomide):
- Refer to Section III for criteria
Cervical Cancer (maintenance therapy):
- Refer to Section III for criteria
Colorectal Cancer (after first-line bevacizumab-containing regimen):
- Refer to Section III for criteria
Endometrial Carcinoma (Uterine Neoplasms) (maintenance therapy)
- Refer to Section III for criteria
PeM* (combination therapy with atezolizumab):
- Refer to Section III for criteria
* Includes use for pericardial mesothelioma and tunica vaginalis testis mesothelioma.
Non-Squamous Non-Small Cell Lung Cancer (maintenance therapy OR continuation therapy in combination with erlotinib):
- Refer to Section III for criteria
Ovarian Fallopian Tube, and Primary Peritoneal Cancer (maintenance therapy):
- Refer to Section III for criteria
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Dosage/Administration 1-6,8,9,14,19,31,37,38,40-49,54
Indication |
Dose |
CRC & Appendiceal Adenocarcinoma |
Administer 5 to 10 mg/kg intravenously every 2 weeks OR 7.5 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity. |
Small Bowel Adenocarcinoma & Ampullary Adenocarcinoma |
Administer 5 mg/kg intravenously every 2 weeks OR 7.5 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity. |
NSCLC, Cervical Cancer, HCC, Vulvar Cancer, PM, & PeM |
Administer 15 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity. |
Adult CNS Cancers |
For disease treatment:
For symptom management:
|
Pediatric CNS Cancers & RCC |
Administer 10 mg/kg intravenously every 2 weeks until disease progression or unacceptable toxicity. |
All Other Indications |
Administer 5 to 10 mg/kg intravenously every 2 weeks OR 7.5 to 15 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity. |
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Billing Code/Availability Information
HCPCS Code(s):
- J9035 – Injection, bevacizumab, 10 mg; 1 billable unit = 10 mg
- Q5107 – Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg; 1 billable unit = 10 mg
- Q5118 – Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg; 1 billable unit = 10 mg
- Q5126 – Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg; 1 billable unit = 10 mg
- Q5129 – Injection, bevacizumab-adcd, biosimilar, (vegzelma), 10 mg; 1 billable unit = 10 mg
- J9999 – Not otherwise classified, antineoplastic drugs (Avzivi only)
NDC(s):
- Avastin single-dose vial, 100 mg/4 mL solution for injection: 50242-0060-xx
- Avastin single-dose vial, 400 mg/16 mL solution for injection: 50242-0061-xx
- Mvasi single-dose vial, 100 mg/4 mL solution for injection: 55513-0206-xx
- Mvasi single-dose vial, 400 mg/16 mL solution for injection: 55513-0207-xx
- Zirabev single-dose vial, 100 mg/4 mL solution for injection: 00069-0315-xx
- Zirabev single-dose vial, 400 mg/16 mL solution for injection: 00069-0342-xx
- Alymsys single-dose vial, 100 mg/4 mL solution for injection: 70121-1754-xx
- Alymsys single-dose vial, 400 mg/16 mL solution for injection: 70121-1755-xx
- Vegzelma single-dose vial, 100 mg/4 mL solution for injection: 72606-0011-xx
- Vegzelma single-dose vial, 400 mg/16 mL solution for injection: 72606-0012-xx
- Avzivi single-dose vial, 100 mg/4 mL solution for injection: 82143-0001-xx
- Avzivi single-dose vial, 400 mg/16 mL solution for injection: 82143-0002-xx
- References
- Avastin [package insert]. South San Francisco, CA; Genentech, Inc.; September 2022. Accessed May 2024.
- Mvasi [package insert]. Thousand Oaks, CA; Amgen, Inc.; February 2023. Accessed May 2024.
- Zirabev [package insert]. New York, NY; Pfizer, Inc.; February 2023. Accessed May 2024.
- Alymsys [package insert]. Bridgewater, NJ; Amneal Pharmaceuticals LLC; April 2022. Accessed May 2024.
- Vegzelma [package insert]. Incheon, Republic of Korea; Celltrion, Inc.; February 2023. Accessed May 2024.
- Avzivi [package insert]. Guangzhou, Guangdong Province, China; Bio-Thera Solutions, Ltd.; December 2023. Accessed May 2024.
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- 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
- 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.
- 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 (2019). Intravenous Cancer Drug Waste Issue Brief. Retrieved from http://www.hoparx.org/images/hopa/advocacy/Issue-Briefs/Drug_Waste_2019.pdf
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- Burger RA, Brady MF, Bookman MA, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med. 2011 Dec 29;365(26):2473-83.
- Pujade-Lauraine E, Hilpert F, Weber B, et al. Bevacizumab Combined With Chemotherapy for Platinum-Resistant Recurrent Ovarian Cancer: The AURELIA Open-Label Randomized Phase III Trial. Journal of Clinical Oncology 2014 32:13, 1302-1308.
- Aghajanian C, Blank SV, Goff BA, et al. OCEANS: a randomized, double-blind, placebo-controlled phase III trial of chemotherapy with or without bevacizumab in patients with platinum-sensitive recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. J Clin Oncol. 2012;30(17):2039–2045.
- Coleman RL, Brady MF, Herzog TJ, et al. Bevacizumab and paclitaxel-carboplatin chemotherapy and secondary cytoreduction in recurrent, platinum-sensitive ovarian cancer (NRG Oncology/Gynecologic Oncology Group study GOG-0213): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2017;18(6):779–791.
- Robert NJ, Diéras V, Glaspy J, et al. RIBBON-1: randomized, double-blind, placebo-controlled, phase III trial of chemotherapy with or without bevacizumab for first-line treatment of human epidermal growth factor receptor 2-negative, locally recurrent or metastatic breast cancer. J Clin Oncol. 2011 Apr 1;29(10):1252-60.
- Agulnik M, Yarber JL, Okuno SH, et al. An open-label, multicenter, phase II study of bevacizumab for the treatment of angiosarcoma and epithelioid hemangioendotheliomas. Ann Oncol. 2013;24(1):257-263. Doi:10.1093/annonc/mds237.
- Lorusso D, Ferrandina G, Colombo N, et al. Randomized phase II trial of carboplatin-paclitaxel (CP) compared to carboplatin-paclitaxel-bevacizumab (CP-B) in advanced (stage III-IV) or recurrent endometrial cancer: The MITO END-2 trial. Journal of Clinical Oncology 2015 33:15_suppl, 5502-5502.
- Miller K, Wang M, Gralow J, et al. Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic breast cancer. N Engl J Med. 2007 Dec 27;357(26):2666-76.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Mesothelioma: Pleural 1.2024. 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 May 2024.
- Zalcman G, Mazieres J, Margery J, et al; French Cooperative Thoracic Intergroup (IFCT). Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016 Apr 2;387(10026):1405-1414.
- Park MS, Patel SR, Ludwig JA, et al. Activity of temozolomide and bevacizumab in the treatment of locally advanced, recurrent, and metastatic hemangiopericytoma and malignant solitary fibrous tumor. Cancer. 2011 Nov 1;117(21):4939-47. Doi: 10.1002/cncr.26098.
- Rose PG, Ali S, Moslemi-Kebria M, et al. Paclitaxel, Carboplatin, and Bevacizumab in Advanced and Recurrent Endometrial Carcinoma. Int J Gynecol Cancer. 2017 Mar;27(3):452-458. Doi: 10.1097/IGC.0000000000000891.
- Aghajanian C, Sill MW, Darcy KM, et al. Phase II trial of bevacizumab in recurrent or persistent endometrial cancer: a Gynecologic Oncology Group study. J Clin Oncol. 2011 Jun 1;29(16):2259-65. Doi: 10.1200/JCO.2010.32.6397.
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- Raghav KPS, Overman MJ, Liu S, et al. A phase II trial of atezolizumab and bevacizumab in patients with relapsed/refractory and unresectable malignant peritoneal mesothelioma. J Clin Oncol 2020;38:9013-9013.
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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 |
C22.0 |
Liver cell carcinoma |
C22.3 |
Angiosarcoma of the liver |
C22.8 |
Malignant neoplasm of liver, primary, unspecified as to type |
C22.9 |
Malignant neoplasm of liver, not specified as primary or secondary |
C24.1 |
Malignant neoplasm of ampulla of Vater |
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 |
C45.0 |
Mesothelioma of pleura |
C45.1 |
Mesothelioma of peritoneum |
C45.2 |
Mesothelioma of pericardium |
C45.7 |
Mesothelioma of other sites |
C45.9 |
Mesothelioma, 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 |
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 |
C56.3 |
Malignant neoplasm of bilateral ovaries |
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 |
C72.1 |
Malignant neoplasm of cauda equina |
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 |
C83.30 |
Diffuse large B-cell lymphoma unspecified site |
C83.39 |
Diffuse large B-cell lymphoma extranodal and solid organ sites |
C83.80 |
Other non-follicular lymphoma unspecified site |
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 |
C85.99 |
Non-Hodgkin lymphoma, unspecified, 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 |
D43.9 |
Neoplasm of uncertain behavior of central nervous system, unspecified |
D48.11x |
Desmoid tumor |
G93.6 |
Cerebral edema |
I67.89 |
Other cerebrovascular disease |
I67.9 |
Cerebrovascular disease, unspecified |
Y84.2 |
Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure |
Z85.038 |
Personal history of other malignant neoplasm of large intestine |
Z85.068 |
Personal history of other malignant neoplasm of small intestine |
Z85.09 |
Personal history of malignant neoplasm of other digestive organs |
Z85.118 |
Personal history of other malignant neoplasm of bronchus and lung |
Z85.42 |
Personal history of malignant neoplasm of other parts of uterus |
Z85.43 |
Personal history of malignant neoplasm of ovary |
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)
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 |
||
Jurisdiction |
NCD/LCA/LCD Document (s) |
Contractor |
6, K |
A52370 |
National Government Services, Inc |
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 |