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Medical Policy: 05.01.15
Original Effective Date: November 2006
Reviewed: February 2008
Revised:
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Panitumumab, marketed under the trade name Vectibix™, is a fully-human monoclonal antibody against the human epidermal growth factor receptor (EGFR), which is over-expressed in many cancers, including colorectal. Clinical studies have shown that panitumumab has significant single-agent activity and improves progression-free survival when compared with best supportive care.
Prior approval is recommended for panitumumab. Submit a prior approval now.
Policy:
Panitumumab may be considered medically necessary for the treatment of EGFR-expressing, metastatic colorectal cancer with disease progression on or following fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy regimens.
All other uses of panitumumab are considered investigational.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- HCPCS J9303 Injection Panitumumab, 10 mg
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Selected References:
- Saif MW, Cohenuram M. Role of panitumumab in the management of metastatic colorectal cancer. Clin Colorectal Cancer. 2006 Jul;692):118-24.
- Gibson TB, Ranganathan A, Grothey A. Randomized phase III trial results of panitumumab, a fully human anti-epidermal growth factor receptor monoclonal antibody, in metastatic colorectal cancer. Clin Colorectal Cancer 2006 May;6(1):13.
- Wainberg Z, Hecht JR. Panitumumab in colon cancer: a review and summary of ongoing trials. Expert Opin Biol Ther. 2006 Nov;6(11):1229-35.
- Siena S, Peeters M, Van Cutsem E et al. Association of progression-free survival with patient-reported outcomes and survival: results from a randomised phase 3 trial of panitumumab. Br J cancer. 2007 Dec 3;97(11):1469-74. Epub 2007 Nov 27.
- Hecht JR, Patnaik A, Berlin J et al. Panitumumab monotherapy in patients with previously treated metastatic colorectal cancer. Cancer. 2007 Sep 1;110(5):980-8.
- Socinski MA. Antibodies to the epidermal growth factor receptor in non small cell lung cancer: current status of matuzumab and panitumumab. Clin Cancer Res. 2007 Aug 1;13(15 pt 2):s4597-601.
- Lopez-Albaitero A, Ferris RL. Immune activation by epidermal growth factor receptor-specific monoclonal antibody therapy for head and neck cancer. Ach Otolarngol Head Neck Surg. 2007 Dec;133(12):1277-81.
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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
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Prior Approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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