Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.082a


Attachment:A

Policy #:MA08.082a

Description:EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA

Title:Pegfilgrastim (Neulasta®) and Related Biosimilars

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA

Note: These are not all-inclusive lists.

Per The National Comprehensive Cancer Network (NCCN) Guidelines, the decision for use of pegfilgrastim (Neulasta®) during the first chemotherapy cycle is based on the disease, type of chemotherapy regimen (i.e., high-dose, dose-dense, or standard-dose therapy), patient risk factors, and treatment intent (i.e., curative or palliative).

The decision for use of pegfilgrastim (Neulasta®) during the second and subsequent chemotherapy cycles is based on whether there was prior febrile neutropenia or a dose-limiting neutropenic event (e.g., a nadir count or day of treatment count that could otherwise impact the planned chemotherapy dose). If there was prior use of a granulocyte-colony stimulating factor (G-CSF), NCCN Guidelines recommend a dose reduction in chemotherapy or a change in the treatment regimen. If there was no prior use of a G-CSF, The NCCN Guidelines indicate to consider using a G-CSF.


EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH RISK FOR FEBRILE NEUTROPENIA (>20%)

Note: This is not an all-inclusive list.

Acute Lymphoblastic Leukemia (ALL)

ALL induction regimens (see NCCN guidelines for ALL)

Bladder Cancer

MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) in neoadjuvant, adjuvant, or metastatic setting

Breast Cancer

Docetaxel + trastuzumab in metastatic or relapsed setting

Dose-dense AC followed by T* (doxorubicin, cyclophosphamide, paclitaxel) in adjuvant setting

TAC (docetaxel, doxorubicin, cyclophosphamide) in adjuvant setting

Esophageal and Gastric Cancers

Docetaxel/cisplatin/fluorouracil

Hodgkin's Lymphoma

BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone)

Kidney Cancer

Doxorubicin/gemcitabine

Non-Hodgkin's Lymphomas

ICE (ifosfamide, carboplatin, etoposide) for the following indications: diffuse large B-cell lymphoma (DLBCL), peripheral T-cell lymphomas (PTCL), 2nd line

RICE* (rituximab, ifosfamide, carboplatin, etoposide)

CHOP-14* (cyclophosphamide, doxorubicin, vincristine, prednisone) with or without rituximab

MINE (mesna, ifosfamide, novantrone, etoposide) for the following indications: DLBCL, 2nd line, or refractory

DHAP (dexamethasone, cisplatin, cytarabine) for the following indications: PTCL, DLBCL, or 2nd line

ESHAP (etoposide, methylprednisolone, cisplatin, cytarabine) for the following indications: DLBCL, PTCL, 2nd line, or recurrent

HyperCVAD + rituximab (cyclophosphamide, vincristine, doxorubicin, dexamethasone + rituximab)

Melanoma

Dacarbazine-based combination (dacarbazine, cisplatin, vinblastine) for advanced, metastatic, or recurrent disease

Dacarbazine-based combination with IL-2, interferon alpha (dacarbazine, cisplatin, vinblastine, IL-2, interferon alpha) for advanced, metastatic, or recurrent disease

Ovarian Cancer

Topotecan

Paclitaxel

Docetaxel

Soft Tissue Sarcoma

MAID (mesna, doxorubicin, ifosfammide, dacarbazine)

Doxorubicin

Ifosfamide/doxorubicin

Small Cell Lung Cancer

Topotecan

Testicular Cancer

VelP (vinblastine, ifosfamide, cisplatin)

VIP (etoposide, ifosfamide, cisplatin)

BEP (bleomycin, etoposide, cisplatin)

TIP (paclitaxel, ifosfamide, cisplatin)


EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH AN INTERMEDIATE RISK FOR FEBRILE NEUTROPENIA (10-20%)

Note: This is not an all-inclusive list.

Occult Primary – Adenocarcinoma

Gemcitabine/docetaxel

Breast Cancer

Docetaxel every 21 days

CMF classic (cyclophosphamide, methotrexate, fluorouracil) in adjuvant setting

AC (doxorubicin, cyclophosphamide) + sequential docetaxel (during taxane portion only) in adjuvant setting

AC + sequential docetaxel + trastuzumab in adjuvant setting

FEC (fluorouracil, epirubicin, cyclophosphamide) + sequential docetaxel

Paclitaxel every 21 days in metastatic or relapsed setting

TC (docetaxel, cyclophosphamide)

Cervical Cancer

Cisplatin/topotecan in recurrent or metastatic setting

Paclitaxel/cisplatin

Topotecan in recurrent or metastatic setting

Irinotecan in recurrent or metastatic setting

Colorectal Cancer

FOLFOX (fluorouracil, leucovorin, oxaliplatin)

Esophageal and Gastric Cancers

Irinotecan/cisplatin

Epirubicin/cisplatin/5-fluorouracil

Epirubicin/cisplatin/capecitabine

Multiple myeloma

DT-PACE (dexamethasone/thalidomide/cisplatin/doxorubicin/cyclophosphamide/etoposide)

DT-PACE + bortezomib (VTD-PACE)

Non-Hodgkin's Lymphomas

EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) for AIDS-related NHL, Burkitt lymphoma, recurrent, other NHL subtypes

EPOCH-IT chemotherapy for AIDS-related NHL, DLBCL, recurrent

GDP (gemcitabine, dexamethasone, cisplatin) for the following indications: DLBCL, PTCL, 2nd line

GDP (gemcitabine, dexamethasone, cisplatin) + rituximab for the following indications: DLBCL, 2nd line, Burkitt lymphoma, other NHL subtypes

FMR (fludarabine, mitoxantrone, rituximab)

CHOP + rituximab (cyclophosphamide, doxorubicin, vincristine, prednisone, rituximab) including regimens with pegylated liposomal doxorubicin or mitoxantrone substituted for doxorubicin

Non-Small Cell Lung Cancer

Cisplatin/paclitaxel in the advanced/metastatic setting

Cisplatin/vinorelbine in the adjuvant, advanced/metastatic setting

Cisplatin/docetaxel in the adjuvant, advanced/metastatic setting

Cisplatin/etoposide in the adjuvant, advanced/metastatic setting

Carboplatin/paclitaxel in the adjuvant, advanced/metastatic setting

Docetaxel in the advanced/metastatic setting

Ovarian Cancer

Carboplatin/docetaxel

Pancreatic Cancer

FOLFIRINOX

Prostate Cancer

Cabazitaxel

Small Cell Lung Cancer

Etoposide/carboplatin

Testicular Cancer

Etoposide/cisplatin

Uterine Sarcoma

Docetaxel in the advanced or metastatic setting



* In general, dose-dense regimens require growth factor support for chemotherapy administration.

Reference:
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology – Myeloid growth factors. V2.2016. 07/27/16. [NCCN Web site]. Available at: https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#myeloid_growth [via free subscription]. Accessed August 25, 2016.




Version Effective Date: 04/22/2019
Version Issued Date: 04/22/2019
Version Reissued Date: N/A

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