|
Medical Policy: 05.01.14
Original Effective Date: September 2006
Reviewed: October 2011
Revised: October 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Bevacizumab, marketed under the trade name Avastin® is a recombinant humanized monoclonal IgG1 antibody that binds to and inhibits the biologic activity of human vascular endothelial growth factor (VEGF), which plays a significant role in tumor angiogenesis, a process necessary for tumor growth and metastasis. Bevacizumab is administered intravenously and is the first FDA-approved therapy designed to inhibit angiogenesis.
 Top
Prior Approval:
Prior approval is recommended. Submit a prior approval/treatment request now.  (95KB)
Top
Policy:
Bevacizumab may be considered medically necessary for the following oncologic indications:
- Metastatic colorectal cancer, with intravenous 5-fluorouracil-based chemotherapy for first- or second-line treatment
- Non-squamous non-small cell lung cancer, with carboplatin and paclitaxel for first-line treatment of unresectable, locally advanced, recurrent or metastatic disease
- Metastatic renal cell carcinoma with interferon alpha
- Metastatic breast cancer, with paclitaxel for treatment of patients who have not received chemotherapy for metastatic HER2-negative breast cancer
- Glioblastoma, as a single agent for patients with progressive disease following prior therapy
- Metastatic ovarian cancer, fallopian tube cancer, and primary peritoneal cancer in patients experiencing relapse or recurrence following primary cytotoxic chemotherapy
All other indications for bevacizumab are considered investigational, including but not limited to:
Prior approval for the treatment of neovascular macular degeneration with Bevacizumab is not recommended or required. For details, see Wellmark’s medical policy for Neovascular Macular Degeneration Treatments
Top
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- J9035 injection, bevacizumab, 10 mg
- J3590 unclassified drugs, when billing bevacizumab intravitreous injections
Top
Selected References:
- Cohen HT, McGovern FJ. Renal Cell Carcinoma. N Engl J Med.353(23):2477-2490.
- Carlson RW, Brown E, Burstein HJ et al. NCCN Task Force Report: Adjuvant Therapy for Breast Cancer. J Natl Compr Canc Netw, 4 Suppl 1(S1-26).
- Miller KD. E2100: A Phase III trial of Paclitaxel Versus Paclitaxel/Bevacizumab for Metastatic Breast Cancer. Clin Breast Cancer 2003;3(6):421-2.
- Hurwitz HI, Fehrenbacher L, Novotny W et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin: for metastatic colorectal cancer. N Engl J Med. 350(23):2335-42.
- Johnson DH, Fehrenbacher L, Novotny WF et al. Randomized phase II trial comparing bevacizumab plus carboplatin and paclitaxel with carboplatin and paclitaxel alone in previously untreated locally advanced or metastatic non-small-cell lung cancer. J Clin Oncol. 22(11):2184-91.
- Yang JC, Hawaorth L, Sherry RM et al. A randomized trial of bevacizumab, an antivascular endothelial growth factor antibody, for metastatic renal cancer. N Engl J Med. 249(5):427-34.
- Tyagi P, Triopathy D. First-line treatment with bevacizumab and paclitaxel prolongs progression-free survival in metastatic breast cancer. Clin Breast Cancer 2005; 6(2):105-7.
- Tyagi P. Bevacizumab, when added to paclitaxel/carboplatin, prolongs survival in previously untreated patients with advanced non-small-cell lung cancer: preliminary results from the ECOG 4599 trial. Clin Lung Cancer. 2005;6(5):276-78.
- Avery RL, Pieramici DJ, Rabena MD et al. Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmology 2006;113:363-72 e5.
- Spaide RF, Laud K, Fine HF et al. Intravitreal bevacizumab treatment of choroidal neovascularization secondary to age-related macular degeneration. Retina 2006; 26:383-90.
- Bashshur ZF, Bazarbachi A, Schakal A et al. Intravitreal bevacizumab for the management of choroidal neovascularization in age-related macular degeneration. Am J Ophthalmol 2006;142:1-9.
- Rich RM, Rosenfeld PJ, Puliafito CA et al. Short-term safety and efficacy of intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration. Retina 2006;26:496-511.
- Scott LJ.Bevacizumab in First-Line Treatment of Metastatic Breast Cancer. Drugs 2007; 67(12):1793-99.
- Lyseng-Williamson KA, Robinson DM. Bevacizumab: a review of its use in advanced colorectal cancer, breast cancer, and NSCLC. Am J Cancer 2006;5(1):43-60.
- Vredenburgh JJ, Desjardins A, Herndon JE et al.Bevacizumab Plus Irinotecan in Recurrent Glioblastoma Multiforme. J Clin Oncol 2007; 25(30):4722-29.
- National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium™. Accessed 08/19/08.
- Escudier B, Pluzanska A, Koralewski P et al. Bevacizumab plus alpha interferon 2a for treatment of metastatic renal cell carcinoma: a randomized, double-blind phase III trial. Lancet. 2007 Dec 22; 370(9605):2103-11.
- Melichar B, Koralewski P, Ravaud A, et al. First line bevacizumab combined with reduced dose interferon alpha 2a is active in patients with metastatic renal cell carcinoma. Ann Oncol. 2008 Aug;19(8):1470-6. E pub 2008 Apr 11
- Van Cutsem E, Vervenne WL, Bennouna J et al. Phase III trial of bevacizumab in combination with gemcitabine and erlotinib in patients with metastatic pancreatic cancer. J Clin Oncol. 2009; 27(13):2231-37.
- Wright JD, Hagemann A, Rader JS et al. Bevacizumab combination therapy in recurrent, platinum-refractory, epithelial ovarian carcinoma: a retrospective analysis. Cancer 2006; 107:83-9.
- Nimeiri HS, OZA AM, Morgan RJ et al. Chicago Phase II Consortium; PMH Phase II Consortium; California Phase II Consortium. Efficacy and safety of bevacizumab plus erlotinib for patients with recurrent ovarian, primary peritoneal and fallopian tube cancer: a trial of the Chicago, PMH, and California Phase II Consortia. Gynecol Oncol. 2008; 110(1):49-55.
- Burger RA, Sill MW, Monk BJ et al. Phase II trial of bevacizumab in persistent or recurrent epithelial ovarian cancer or primary peritoneal cancer: a Gynecologic Oncology Group Study. J Clin Oncol 2007 Nov 20; 25(33):5165-71.
- Horita Y, Yamada Y, Kato K et al. Phase II clinical trial of second-line FOLFIRI plus bevacizumab for patients with metastatic colorectal cancer: AVASIRI trial. Int J Clin Oncol. 2011 Oct 15. [Epub ahead of print].
- Reardon DA, Herndon JE 2nd, Peters K et al. Outcome after bevacizumab clinical trial therapy among recurrent grade III malignant glioma patients. J Neurooncol. 2011 Oct 14. [Epub ahead of print].
- Brufsky AM, Hurvitz S, Perez E et al. RIBBON-2: A Randomized, Double-blind, Pacebo-controlled, Phase III Trial Evaluating the Efficacy and Safety of Bevacizumab in Combination with Chemotherapy for Second-line Treatment of Human Epidermal Growth Factor Receptor 2-Negative Metastatic Breast Cancer. J Clin Oncol. 2011 Oct 11. [Epub ahead of print].
- Reardon DA, Desjardins A, Peters KB et al. Phase II study of carboplatin, irinotecan, and bevacizumab for bevacizumab naïve, recurrent glioblastoma. J Neurooncol. 2011 Oct 11. [Epub ahead of print].
- Ready NE, Dudek AZ, Pang HH et al. Cisplatin, irinotecan, and bevacizumab for untreated extensive-stage small-cell lung cancer: CALGB 30306, a Phase II study. J Clin Oncol. 2011 Oct 3. [Epub ahead of print].
Top
Policy History:
Date Reason Action
October 2010 Annual review Policy revised
October 2011 Annual review Policy renewed
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
|
 |
