When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin 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 Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Salzer W, Asselin B, SUpko, et. al. Erwinina asparaginase achieves therapeutic activity after pegaspargase allergy: a report from the Children's Oncology Group. Blood. 2013;122(4):507-514
Seiter K. Acute lymphoblastic leukemia treatment & management. [ Medscape Website]. 07/17/2018. Available at: http://emedicine.medscape.com/article/207631-treatment. Accessed October 9, 2019.
US Department of Health and Human Services. Common terminology criteria for adverse events (CTCTAE). V5.0. 11/27/2017. Available at: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf. Accessed October 9, 2019.
US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Approval letter. Asparaginase Erwinia chrysanthemi (Erwinaze®). [FDA Web site]. 03/29/2016. Available at:
http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2011/125359s000ltr.pdf. Accessed October 9, 2019.
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.02 Acute lymphoblastic leukemia, in relapse
Policy: 08.00.15f:Off-label Coverage for Prescription Drugs and/or Biologics