Medical Policy: 02.04.66 

Original Effective Date: May 2017 

Reviewed: May 2017 

Revised:  

 

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:

Treatment of acute myeloid leukemia (AML) is based on risk stratification, primarily related to patient age and tumor cytogenetics. AML has a highly heterogeneous clinical course, and treatment generally depends on the different risk-stratification categories. Depending on the risk-stratification category, treatment modalities may include intensive remission induction chemotherapy, hypomethylating agents, clinical trials with innovative compounds, palliative cytotoxic treatment, new medication regimes, or supportive care only. For patients who achieve complete remission (CR) after induction treatment, possible postremission treatment options include intensive consolidation therapy, maintenance therapy, or autologous or allogeneic hematopoietic cell transplant. In patients with cytogenetically normal AML, the identification of variants in several genes, including FLT3, NPM1, and CEBPA, has been proposed to allow for further segregation in the management of this heterogeneous disease.

 

The most recent World Health Organization (WHO) classification (2016) reflects the increasing number of acute leukemias that can be categorized based on underlying cytogenetic abnormalities (ie, at the level of the chromosome including chromosomal translocations or deletions) or molecular genetic abnormalities (ie, at the level of the function of individual genes, including gene variants). These cytogenetic and molecular changes form distinct clinico-pathologic-genetic entities with diagnostic, prognostic, and therapeutic implications. Conventional cytogenetic analysis (karyotyping) is considered to be a mandatory component in the diagnostic evaluation of a patient with suspected acute leukemia, because the cytogenetic profile of the tumor is considered to be the most powerful predictor of prognosis in AML and is used to guide the current risk-adapted treatment strategies.

 

Molecular variants have been analyzed to subdivide AML with normal cytogenetics into prognostic subsets. In AML, 3 of the most frequent molecular changes with prognostic impact are variants of CEBPA, encoding a transcription factor, variants of the FLT3 gene, encoding a receptor of tyrosine kinase involved in hematopoiesis, and variant of the NPM1 gene, encoding a shuttle protein within the nucleolus. “AML with mutated NPM1 or CEBPA” were included as categories in the 2016 WHO classification of acute leukemias. AML with FLT3 variants is not considered a distinct entity in the 2016 classification. The 2008 WHO classification recommends determining the presence of FLT3 variants because of the prognostic significance.

 

For individuals who have cytogenetically normal AML who receive genetic testing for variants in FLT3, NPM1, CEBPA to risk-stratify AML, the evidence includes retrospective observational studies and systematic reviews of these studies. Relevant outcomes are overall survival, disease-specific survival, test accuracy and validity, and treatment-related mortality and morbidity. FLT3 internal tandem duplication (FLT3-ITD) variants confer a poor prognosis, whereas NPM1 (without FLT3-ITD variant) and biallelic CEBPA variants confer a favorable prognosis. The prognostic effect of FLT3 tyrosine kinase domain variants is uncertain. Data have suggested an overall survival benefit with transplantation for patients with FLT3-ITD, but do not clearly demonstrate an overall survival benefit of transplantation for patients with NPM1 and CEBPA variants.

 

Major professional societies and practice guidelines have recommended testing for these variants to risk-stratify and to inform treatment management decisions, including possible hematopoietic cell transplant, treatment intensity, and medication selection. The U.S. Food and Drug Administration recently approved Rydapt (midostaurin) for the treatment of adult patients with newly diagnosed acute myeloid leukemia (AML) who have a specific genetic mutation (FLT3), in combination with chemotherapy.

 

National Comprehensive Cancer

Network Current National Comprehensive Cancer Network guidelines for acute myeloid leukemia (AML)13 (v1.2017) provide the following recommendations:

 

For the evaluation for acute leukemia, “bone marrow with cytogenetics (karyotype FISH [fluorescence in situ hybridization]) and molecular analyses (KIT, FLT3-ITD, NPM1, CEBPA, and other mutations).”

 

“Molecular abnormalities (KIT, FLT3-ITD, NPM1, CEBPA, and other mutations) are important for prognostication in a subset of patients (category 2A) and may guide therapeutic intervention (category 2B). These are useful for patients with normal karyotype (especially FLT3-ITD, NPM1 mutations) or core binding factor leukemia (especially KIT mutation).”

 

Prior Approval:

 

Not recommended

 

Policy:

Genetic testing for FLT3 internal tandem duplication (FLT3-ITD), NPM1, and CEBPA variants may be considered medically necessary in cytogenetically normal acute myeloid leukemia

 

Genetic testing for FLT3 internal tandem duplication (FLT3-ITD), NPM1, and CEBPA variants is considered investigational in all other situations.

 

Genetic testing for FLT3 tyrosine kinase domain (FLT3-TKD) variants is considered investigational.

 

Genetic testing for FLT3, NPM1, and CEBPA variants to detect minimal residual disease is considered investigational.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 81218  CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence
  • 81245  FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15)
  • 81246  FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836)
  • 81310  NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 variants.
  • 0023U  Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin

 

Selected References:

  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practive Guidelies in Oncology: Acute Myeloid Leukemia. Version 1.2017.
  • Port M, Bottcher M, Thol F, et al. Prognostic significance of FLT3 internal tandem duplication, nucleophosmin 1, and CEBPA gene mutations for acute myeloid leukemia patients with normal karyotype and younger than 60 years: a systematic review and meta-analysis. Ann Hematol. Aug 2014;93(8):1279-1286. PMID 24801015
  • Dickson GJ, Bustraan S, Hills RK, et al. The value of molecular stratification for CEBPA(DM) and NPM1(MUT) FLT3(WT) genotypes in older patients with acute myeloid leukaemia. Br J Haematol. Feb 2016;172(4):573-580. PMID 26847745
  • Wu X, Feng X, Zhao X, et al. Prognostic significance of FLT3-ITD in pediatric acute myeloid leukemia: a meta-analysis of cohort studies. Mol Cell Biochem. Sep 2016;420(1-2):121-128. PMID 27435859
  • Schlenk RF, Dohner K, Krauter J, et al. Mutations and treatment outcome in cytogenetically normal acute myeloid leukemia. N Engl J Med. May 1 2008;358(18):1909-1918. PMID 18450602
  • Schlenk RF, Taskesen E, van Norden Y, et al. The value of allogeneic and autologous hematopoietic stem cell transplantation in prognostically favorable acute myeloid leukemia with double mutant CEBPA. Blood. Aug 29 2013;122(9):1576-1582. PMID 23863898
  • Willemze R, Suciu S, Meloni G, et al. High-dose cytarabine in induction treatment improves the outcome of adult patients younger than age 46 years with acute myeloid leukemia: results of the EORTC-GIMEMA AML-12 trial. J Clin Oncol. Jan 20 2014;32(3):219-228. PMID 24297940
  • Chou SC, Tang JL, Hou HA, et al. Prognostic implication of gene mutations on overall survival in the adult acute myeloid leukemia patients receiving or not receiving allogeneic hematopoietic stem cell transplantations. Leuk Res. Nov 2014;38(11):1278-1284. PMID 25260824
  • Ma Y, Wu Y, Shen Z, et al. Is allogeneic transplantation really the best treatment for FLT3/ITD-positive acute myeloid leukemia? A systematic review. Clin Transplant. Feb 2015;29(2):149-160. PMID 25430616
  • Tarlock K, Alonzo TA, Gerbing RB, et al. Gemtuzumab ozogamicin reduces relapse risk in FLT3/ITD acute myeloid leukemia: a report from the Children's Oncology Group. Clin Cancer Res. Apr 15 2016;22(8):1951-1957. PMID 26644412
  • Ahn JS, Kim JY, Kim HJ, et al. Normal karyotype acute myeloid leukemia patients with CEBPA double mutation have a favorable prognosis but no survival benefit from allogeneic stem cell transplant. Ann Hematol. Jan 2016;95(2):301-310. PMID 26537612
  • Brunner AM, Li S, Fathi AT, et al. Haematopoietic cell transplantation with and without sorafenib maintenance for patients with FLT3-ITD acute myeloid leukaemia in first complete remission. Br J Haematol. Nov 2016;175(3):496-504. PMID 27434660
  • Bornhäuser M, Illmer T, Schaich M, et al. Improved outcome after stem-cell transplantation in FLT3/ITD-positive AML. Blood. Mar 1 2007;109(5):2264-2265; author reply 2265. PMID 17312001
  • DeZern AE, Sung A, Kim S, et al. Role of allogeneic transplantation for FLT3/ITD acute myeloid leukemia: outcomes from 133 consecutive newly diagnosed patients from a single institution. Biol Blood Marrow Transplant. Sep 2011;17(9):1404-1409. PMID 21324374
  • Guieze R, Cornillet-Lefebvre P, Lioure B, et al. Role of autologous hematopoietic stem cell transplantation according to the NPM1/FLT3-ITD molecular status for cytogenetically normal AML patients: a GOELAMS study. Am J Hematol. Dec 2012;87(12):1052-1056. PMID 22911473
  • Meshinchi S, Alonzo TA, Stirewalt DL, et al. Clinical implications of FLT3 mutations in pediatric AML. Blood. Dec 01 2006;108(12):3654-3661. PMID 16912228
  • Liersch R, Muller-Tidow C, Berdel WE, et al. Prognostic factors for acute myeloid leukaemia in adults--biological significance and clinical use. Br J Haematol. Apr 2014;165(1):17-38. PMID 24484469
  • John Hopkins University, Targeting FLT3 to treat leukemia. Expert Opin Ther Targets: Jan 2016; 19(1): 37-54. Doi:10.1517/14728222.2014
  • Fey M, Buske C, Acute myeloblastic leukaemias in adult patients: ESMO clinical practice guidelines for diagnosis, treatment, and follow-up. Annals of Oncology. Aug 2013. Doi: 10.1093/annonc/mdt320.
  • FDA US Food and Drug Administration Rydapt approval label.

 

Policy History:

May 2017 - New Policy

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.

 

*CPT® is a registered trademark of the American Medical Association.