Bevacizumab*

Medical Policy: 05.01.14 
Original Effective Date: September 2006 
Reviewed: November 2007 
Revised: August 2008 

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: 

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.

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

Policy: 

Bevacizumab may be considered medically necessary for the following indications:

  • In combination with fluorouracil-based chemotherapy for first-line or second-line treatment of metastatic colon or rectal cancer
  • In combination with platinum-based chemotherapy for first-line treatment of non-squamous non-small-cell lung cancer (NSCLC)
  • To treat metastatic clear-cell renal cell carcinoma in patients who have failed or are ineligible for interleukin-2 therapy
  • In combination with taxane-based chemotherapy for previously untreated, locally recurrent or metastatic HER2-negative breast cancer.  
  • To treat neovascular age-related macular degeneration
  • Recurrence or palliative therapy in combination with irinotecan for glioblastoma multiforme in any of the following settings:
    • Diffuse or multiple recurrent disease
    • Resectable local recurrent disease without carmustine polymer
    • Unresectable local recurrent disease

All other indications for bevacizumab are considered investigational, including but not limited to:

  • Ovarian cancer
  • Hepatocellular carcinoma
  • Esophageal cancer
  • Pancreatic cancer
  • Multiple sclerosis  

See also policy 09.03.03 Neovascular Macular Degeneration Treatments


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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.
  • Use HCPCS code J9035 injection, bevacizumab, 10 mg

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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™.  http://www.nccn.org/professionals/drug_compendium/MatrixGenerator/HTML/Bevacizumab.asp. Accessed 08/19/08. 

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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.