Contact Us
Plans and Services Health and Wellness About Wellmark Member Employer Producer Provider
Home Provider Medical Policies and Authorizations Alphabetical Listing


» Working with Wellmark.com
» News
» BlueCard®
» Claims and Payment
» Medical Policies and Authorizations
» Health Management
» Credentialing and Contracting
» Medical, Dental, and Pharmacy
» Quality and Transparency
» Communications and Resources
» Health Care Reform for Providers
printer friendly Printer-Friendly Page

Avastin® (bevacizumab) for Non-Ophthalmologic Conditions*

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 05.01.14 
Original Effective Date: September 2006 
Reviewed: May 2015 
Revised: May 2015 


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: 

The intent of the Avastin® (bevacizumab) drug policy is to ensure appropriate selection of patients for therapy based on product labeling, clinical guidelines and clinical studies.  Bevacizumab is a recombinant humanized IgG1 monoclonal 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.

 

Bevacizumab is approved by the Food and Drug Administration (FDA) for the following indications:

  • In combination with intravenous 5-fluorouracil (5-FU)-based chemotherapy for first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum.
  • In combination with fluoropyrimidine- irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment of patients with metastatic carcinoma of the colon or rectum who have progressed on a first-line Avastin®-containing regimen.
  • In combination with carboplatin and paclitaxel for first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non-squamous, non-small cell lung cancer. 
  • As single agent treatment for patients with glioblastoma with progressive disease following prior therapy.
  • In combination with interferon alfa for treatment of patients with metastatic renal cell carcinoma
  • In combination with paclitaxel, pegylated liposomal doxorubicin or topotecan for the treatment of platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer, who received no more than two chemotherapy regimens
  • In combination with paclitaxel, doxorubicin liposomal, or topotecan for treatment of platinum-resistant recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in patients who received no more than 2 prior chemotherapy regimens

Top


Prior Approval: 

 

Prior approval is required. Submit a prior approval/treatment request now .


Top


Policy: 

I. Bevacizumab is considered medically necessary for any of the following indications:

  • Advanced or metastatic colorectal cancer
  • Anaplastic gliomas
  • Angiosarcoma
  • Cervical cancer
  • Endometrial cancer
  • Glioblastoma
  • Hemangiopericytoma
  • Metastatic renal cell cancer
  • Non-squamous non-small cell lung (NSCLC) cancer
  • Progressive or recurrent adult intracranial ependymoma
  • Solitary fibrous tumors

 

II. Bevacizumab is considered medically necessary for the treatment of breast cancer when ONE of the following criteria are met:

  • Patient has recurrent or metastatic disease that is  hormone receptor-positive, HER2-negative with visceral crisis in combination with paclitaxel; OR
  • Patient has recurrent or metastatic disease that is HER2-negative and either hormone receptor-negative or hormone receptor-positive and endocrine therapy refractory in combination with paclitaxel; OR
  • Patient has recurrent or metastatic disease that is progressive with no clinical benefit after three consecutive endocrine therapy regimens or with symptomatic visceral disease in combination with paclitaxel

III. Bevacizumab is considered medically necessary for the treatment of ovarian cancer when ONE of the following criteria are met:

  • Patient has an ovarian stromal tumor (stage II-IV granulose cell tumor) for which bevacizumab is being used following clinical relapse; OR
  • Patient has platinum-resistant recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer, in which bevacizumab has not been previously received, and is being used in combination with liposomal doxorubicin, paclitaxel, or topotecan; OR
  • Patient has persistent or recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer, in which brevacizumab has not been previously received, and is being used as a single agent

Approval will be for lifetime for patients who meet any of the afore-mentioned medical necessity criteria.

 

 

IV. Bevacizumab is considered not medically necessary for patients who do not meet the criteria set forth above.

 

 

CLIINICAL RATIONALE

 

The policy recognizes the FDA approved and NCCN compendia supported uses (2A recommendation or better) of bevacizumab as medically necesary.





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

Top


Selected References: 

  • Avastin®. [package insert]. South San Francisco, CA: Genentech, Inc; March 2013.
  • The NCCN Drugs and Biologics Compendium (NCCN Compendium&trade). Avastin (bevacizumab). Available at http://www.nccn.org/professionals/drug_compendium/matrixgenerator/matrix.aspx?aid=1 . Accessed March 12, 2015
  • U.S. Food and Drug Administration; "FDA begins process to remove breast cancer indication from Avastin label." http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm237172.html

Top


Policy History: 

Date                                        Reason                               Action

October 2010                         Annual review                     Policy revised

October 2011                         Annual review                     Policy renewed

October 2012                         Annual review                     Policy revised

January 2013                          Interim review                     Policy revised

August 2013                           Annual review                     Policy revised

August 2014                           Annual review                     Policy revised

May 2015                               Annual review                     Policy revised


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 © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
FacebookTwitterInstagrampinterestLinked InYou Tube