Commercial

Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
08.00.66o

Policy

​​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.

MEDICALLY NECESSARY

COMPANY-DESIGNATED PREFERRED PRODUCTS
Although there are many bevacizumab products on the market (e.g., bevacizumab [Avastin®], bevacizumab-awwb [Mvasi™], bevacizumab-bvzr [Zirabev™]), there is no reliable evidence of the superiority of any one product of bevacizumab compared to other products. The Company has designated the following bevacizumab biosimilar products as its preferred products: bevacizumab-awwb (Mvasi™) and bevacizumab-bvzr (Zirabev™).

These products are less costly and at least as likely to produce equivalent therapeutic results as the non-preferred products, which includes, but are not limited to bevacizumab (Avastin®) and any other non-preferred bevacizumab biosimilars.

According to the United States Food and Drug Administration (FDA) “a biosimilar is a biological product that has no clinically meaningful differences from the existing FDA-approved reference product. All biosimilar products meet the FDA’s rigorous standards for approval for the indications described in the product labeling. Once a biosimilar has been approved by the FDA, the safety and effectiveness of these products have been established, just as they have been for the reference product.” Coverage of a biosimilar product as an alternate to a reference product is not considered a form of step therapy by the Company.

NON-PREFERRED PRODUCTS
Use of non-preferred products, bevacizumab (Avastin®) or any non-preferred biosimilar,​​​ is considered medically necessary and, therefore, covered only for individuals who are currently receiving or have previously received a non-preferred product for the specified bevacizumab indication.

If the individual has not previously received non-preferred product to treat the specified indication, these non-preferred products are eligible for coverage when the individual has documented contraindication(s) or intolerance(s) to the Company designated preferred products.

BEVACIZUMAB AND RELATED BIOSIMILARS
Bevacizumab and related biosimilars are considered medically necessary and, therefore, covered for the following indications when the dosing and frequency requirements listed in Attachment A and the requirements listed in the COMPANY-DESIGNATED PREFERRED PRODUCTS and NON-PREFERRED PRODUCTS Sections above are met:

BREAST CARCINOMA, INVASIVE
In combination with paclitaxel in individuals with high tumor burden, rapidly progressing disease, and visceral crisis for recurrent or stage IV (M1) human epidermal growth factor receptor 2 (HER2)--negative disease that meets any of the following criteria:
  • Hormone receptor--negative
  • Hormone receptor--positive with visceral crisis or endocrine therapy refractory
CENTRAL NERVOUS SYSTEM TUMORS
  • Treatment of recurrent anaplastic glioma or ​recurrent glioblastoma​ disease as a single agent (NCCN-preferred) or in combination with carmustine, lomustine, or temozolomide if bevacizumab monotherapy fails and it is desirable to continue the steroid sparing effects of bevacizumab 
  • As short-course single agent therapy for management of symptoms driven by RT necrosis, poorly controlled vasogenic edema, or mass effect for any of the following conditions:
    • Adult low-grade (WHO grade II) infiltrative supratentorial astrocytoma/oligodendroglioma
    • Anaplastic glioma
    • Glioblastoma
    • Adult intracranial and spinal ependymoma (excludes subependymoma)
    • Adult medulloblastoma
    • Primary central nervous system lymphoma
    • Meningiomas
    • Brain metastases (limited or extensive)
    • Metastatic spine tumors
  • Treatment as a single-agent for disease progression or recurrent adult intracranial and spinal ependymoma (excludes subependymoma) if received prior RT and individuals has any of the following:
    • ​gross total or subtotal resection with negative CSF cytology
    • subtotal resection​ and evidence of metastasis (brain, spine, or CSF)
    • ​unresectable disease
  • ​​Treatment as single agent for surgically inaccessible recurrent or progressive meningiomas when radiation is not possible.
CERVICAL CARCINOMA
  • In combination with paclitaxel and cisplatin or paclitaxel and topotecan for persistent, recurrent, or metastatic carcinoma of the cervix
  • First-line or second-line therapy as clinically appropriate (if not used previously as first-line) for local/regional recurrence or Stage IVB or distant metastases in combination with paclitaxel and cisplatin (NCCN-preferred regimen), paclitaxel and carboplatin (NCCN-preferred regimen), or paclitaxel and topotecan (NCCN-preferred regimens)
  • Second-line therapy for persistent, recurrent, or metastatic small cell neuroendocrine carcinoma of the cervix (NECC)
    • ​​in combination with paclitaxel and cisplatin (NCCN-preferred regimen)
    • in combination with paclitaxel and carboplatin (NCCN-preferred regimen)
    • in combination with paclitaxel and topotecan ​
COLON OR RECTAL CARCINOMA: ADENOCARCINOMA
Colorectal
  • In individuals who have metastatic carcinoma of the colon or rectum, as first- or second-line treatment, in combination with intravenous 5-fluorouracil--based chemotherapy (e.g., IFL [irinotecan, fluorouracil, leucovorin] or FOLFOX4 [fluorouracil, leucovorin, oxaliplatin])
  • In individuals who have metastatic carcinoma of the colon or rectum, as a second-line treatment in individuals who have progressed on a first-line bevacizumab (or related biosimilar) regimen, in combination with fluoropyrimidine-, irinotecan-, or fluoropyrimidine-oxaliplatin--based chemotherapy
  • For colon or rectal carcinoma as National Comprehensive Cancer Network's (NCCN) preferred anti-angiogenic therapy as primary treatment for individuals with unresectable metachronous metastases and previously received adjuvant FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or CapeOX (capecitabine and oxaliplatin) within the past 12 months:
    • In combination with irinotecan
    • In combination with FOLFIRI (fluorouracil, leucovorin, and irinotecan) regimen
  • For colon or rectal carcinoma as subsequent therapy for progression of advanced or metastatic disease:
    • In combination with FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or CapeOX (capecitabine and oxaliplatin) regimen for disease previously treated with irinotecan-based therapy without oxaliplatin
    • In combination with FOLFOX, CapeOX, or irinotecan and oxaliplatin for individuals previously treated with fluoropyrimidine therapy without irinotecan or oxaliplatin
    • As the NCCN-preferred anti-angiogenic agent in combination with irinotecan or with FOLFIRI (fluorouracil, leucovorin, and irinotecan) regimen in individuals previously treated with one of the following regimens:
      • fluoropyrimidine therapy without irinotecan or oxaliplatin
      • oxaliplatin-based therapy without irinotecan
Colon
  • For colon carcinoma, as initial ​treatment for unresectable synchronous liver and/or lung metastases in combination with one of the following regimens:
    • FOLFOX (fluorouracil, leucovorin, and oxaliplatin) regimen
    • FOLFIRI (fluorouracil, leucovorin, and irinotecan) regimen
    • FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin and irinotecan) regimen
    • CapeOX (capecitabine and oxaliplatin) regimen
  • For colon carcinoma, in combination with capecitabine or fluorouracil/leucovorin ​in individuals not appropriate for intensive therapy for any of the following indications:
    • as primary treatment for locally unresectable or medically inoperable disease
    • for unresectable synchronous liver and/or lung metastases that remain unresectable after primary systemic therapy
    • as primary treatment for synchronous abdominal/peritoneal metastases that are nonobstructing, or following local therapy for individuals with imminent or existing obstruction
    • for unresectable synchronous metastases of other sites
    • as primary treatment for unresectable metachronous metastases in individuals who have not received previous adjuvant FOLFOX or CapeOX within the past 12 months, who have received previous fluorouracil/leucovorin (5-FU/LV) or capecitabine therapy, or who have not received any previous chemotherapy
    • for unresectable metachronous metastases that remain unresectable after primary treatment
  • For colon carcinoma, in combination with FOLFOX, FOLFIRI, CapeOX, or FOLFOXIRI ​in individuals appropriate for intensive therapy, for any of the following indications:
    • as primary treatment for locally unresectable or medically inoperable disease
    • for unresectable synchronous liver and/or lung metastases that remain unresectable after primary systemic therapy
    • as primary treatment for synchronous abdominal/peritoneal metastases that are nonobstructing, or following local therapy for individuals with imminent or existing obstruction
    • for unresectable synchronous metastases of other sites
    • as primary treatment for unresectable metachronous metastases in individuals who have not received previous adjuvant FOLFOX or CapeOX within the past 12 months, who have received previous fluorouracil/leucovorin (5-FU/LV) or capecitabine therapy, or who have not received any previous chemotherapy
    • for unresectable metachronous metastases that remain unresectable after primary treatment
    • for progression on non-intensive therapy, except if received previous fluoropyrimidine, with improvement in functional status ​
Rectal
  • Therapy in combination with FOLFOX (fluorouracil, leucovorin, and oxaliplatin), FOLFIRI (fluorouracil, leucovorin, and irinotecan) ​or CapeOX (capecitabine and oxaliplatin) regimen​ as primary treatment for T3, N Any; T1-2, N1-2; T4, N Any; or locally unresectable or medically inoperable disease if resection is contraindicated following neoadjuvant therapy, in individuals appropriate for intensive therapy
  • Therapy in combination with capecitabine or 5-FU/leucovorin (fluorouracil and leucovorin) regimen​ as primary treatment for T3, N Any; T1-2, N1-2; T4, N Any; or locally unresectable or medically inoperable disease if resection is contraindicated following neoadjuvant therapy, in individuals not appropriate for intensive therapy ​
  • Therapy in combination with FOLFOX, FOLFIRI , CapeOX, ​or FOLFOXIRI regimen, in individuals appropriate for intensive therapy 
    • for synchronous liver only and/or lung only metastases that are unresectable or medically inoperable and remain unresectable (with no progression of primary tumor) after primary systemic therapy
    • ​following palliative short-course radiation therapy (RT) or chemo/RT for synchronous liver only and/or lung only metastases that are unresectable or medically inoperable and remain unresectable (with progression of primary tumor) after primary systemic therapy
    • as primary treatment for synchronous abdominal/peritoneal metastases that are nonobstructing, or following local therapy for individuals with existing or imminent obstruction
    • as primary treatment for synchronous unresectable metastases of other sites
    • as primary treatment for unresectable metachronous metastases in individuals who have not received previous adjuvant FOLFOX or CapeOX within the past 12 months, who have received previous fluorouracil/leucovorin (5-FU/LV) or capecitabine therapy, or who have not received any previous chemotherapy
    • for unresectable metachronous metastases that remain unresectable after primary treatment
    • for progression on non-intensive therapy, except if received previous fluoropyrimidine, with improvement in functional status ​​
  • Therapy in combination with capecitabine or 5-FU/leucovorin (fluorouracil and leucovorin) regimen in individuals not appropriate for intensive therapy

    • for synchronous liver only and/or lung only metastases that are unresectable or medically inoperable and remain unresectable (with no progression of primary tumor) after primary systemic therapy
    • following palliative radiation therapy (RT) or chemo/RT for synchronous liver only and/or lung only metastases that are unresectable or medically inoperable and remain unresectable (with progression of primary tumor) after primary systemic therapy
    • as primary treatment for synchronous abdominal/peritoneal metastases that are nonobstructing, or following local therapy for individuals with existing or imminent obstruction
    • as primary treatment for synchronous unresectable metastases of other sites
    • as primary treatment for unresectable metachronous metastases in individuals who have not received previous adjuvant FOLFOX or CapeOX within the past 12 months, who have received previous fluorouracil/leucovorin (5-FU/LV) or capecitabine therapy, or who have not received any previous chemotherapy
    • for unresectable metachronous metastases that remain unresectable after primary treatment​
  • ​​​​​​​​Primary treatment for synchronous liver only and/or lung only metastases that are unresectable or medically inoperable in combination with one of the following:
    • FOLFIRI (fluorouracil, leucovorin, and irinotecan) regimen
    • FOLFOX (fluorouracil, leucovorin, and oxaliplatin) regimen
    • CapeOX (capecitabine and oxaliplatin) regimen
    • FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) regimen​
​HEPATOCELLULAR CARCINOMA 
  • ​In individuals with unresectable or metastatic hepatocellular carcinoma (HCC) who have not received prior systemic therapy, in combination with atezolizumab (Tecentriq)
KIDNEY CARCINOMA
  • In individuals who have metastatic renal cell carcinoma (mRCC) in combination with interferon alpha
  • In individuals with relapsed or stage IV kidney cancer with one of the following conditions:
    • clear cell histology in combination with interferon alfa-2b as first-line therapy
    • non-clear cell histology as a single agent
    • in combination with erlotinib for non-clear cell histology in selected individuals with advanced papillary renal cell carcinoma including hereditary leiomyomatosis and renal cell cancer (HLRCC)
    • in combination with everolimus as systemic therapy for non-clear cell histology
MALIGNANT PLEURAL MESOTHELIOMA 
 In combination with pemetrexed and either cisplatin (NCCN-preferred regimen) or carboplatin (in individuals not eligible for cisplatin) followed by single-agent maintenance bevacizumab as treatment of one of the following:
  • unresectable clinical stage I-IIIA disease and tumors of epithelial histology or sarcomatoid or mixed biphasic histology
  • clinical stage IIIB or IV disease, sarcomatoid, or medically inoperable tumors in individuals with performance status (PS) 0-2
NON-SQUAMOUS NON-SMALL CELL LUNG CANCER (NSCLC): ADENOCARCINOMA AND LARGE CELL CARCINOMA
  • In individuals who have unresectable, locally advanced, recurrent, or metastatic NSCLC, as first-line treatment in combination with paclitaxel (Taxol®) and carboplatin (Paraplatin®)
  • In combination with erlotinib for sensitizing EGFR mutation-positive nonsquamous cell histology, recurrent, advanced or metastatic disease with no history of hemoptysis as either first-line therapy or continuation of therapy following disease progression on combination of erlotinib with bevacizumab for asymptomatic disease, symptomatic brain lesions, or isolated symptomatic systemic lesions​ 

  • Treatment for recurrent, advanced, or metastatic disease** as first-line therapy for PD-L1 expression positive (≥1%) tumors that are EGFR, ALK, ROS1, BRAF, MET 14 skipping mutation, and RET negative or unknown and no contraindications to PD-1 or PD-L1 inhibitors the addition of pembrolizumab or atezolizumab and performance status (PS) 0-2 in combination with atezolizumab, carboplatin and paclitaxel for nonsquamous cell histology 
  • In combination with carboplatin and either paclitaxel or pemetrexed (if contraindications to PD-1 or PD-L1 inhibitors the addition of pembrolizumab or atezolizumab), or in combination with cisplatin and pemetrexed (if contraindications to PD-1 or PD-L1 inhibitors the addition of pembrolizumab or atezolizumab), or in combination with atezolizumab, carboplatin and paclitaxel (if no contraindications to PD-1 or PD-L1 inhibitors the addition of pembrolizumab or atezolizumab) for recurrent, advanced or metastatic disease** in individuals with PS 0 to 1, tumors of nonsquamous cell histology, and no history of recent hemoptysis for one of the following regimens: 
    • ​initial systemic therapy for EGFR, ALK, ROS1, BRAF, MET 14 skipping mutation, and RET negative or unknown, and PD-L1 <1% or unknown
    • first-line or subsequent therapy for BRAF V600E-mutation, NTRK gene fusion positive tumors​, MET 14 skipping mutationand RET​ rearrangment positive tumors
    • subsequent therapy for sensitizing EGFR mutation-positive tumors and prior erlotinib plus or minus (ramucirumab or bevacizumab), afatinib, gefitinib, osimertinib, or dacomitinib therapy
    • subsequent therapy for ALK rearrangement-positive tumors and prior crizotinib, ceritinib, alectinib, or brigatinib therapy
    • subsequent therapy for ROS1 rearrangement-positive tumors and prior crizotinib, ​entrectinib, or ceritinib therapy
    • subsequent therapy ​(except for PD-1/PD-L1 containing regimens) for PD-L1 expression-positive (≥1%) tumors and EGFR, ALK, ROS1, BRAF, MET 14 skipping mutation, and RET negative or unknown, and no prior platimun-doublet chemotherapy but with a PD-1/PD-L1 inhibitor
  • Continuation maintenance therapy as a single agent or in combination with atezolizumab for recurrent, advanced or metastatic disease** for PD-L1 expression positive (≥1%) tumors that are EGFR, ALK, ROS1, BRAF, MET exon 14 skipping mutation, and RET​ negative or unknown and no contraindications to PD-1 or PD-L1 inhibitors the addition of pembrolizumab or atezolizumab in individuals with PS 0-2 who achieve a response or stable disease following first-line therapy with atezolizumab/carboplatin/paclitaxel/bevacizumab for nonsquamous cell histology​ 
  • Continuation Maintenance therapy for recurrent, advanced, or metastatic disease** in individuals with performance status 0 to 2, tumors of nonsquamous cell histology, and no history of recent hemoptysis who achieve tumor response or stable disease following initial systemic therapy, with one of the following regimens: 
    • ​as single-agent
    • in combination with pemetrexed (if previously used with a first-line pemetrexed/platinum chemotherapy regimen)
    • in combination with atezolizumab (if previously used first-line as part of an atezolizumab/carboplatin/paclitaxel/bevacizumab regimen) ​for nonsquamous cell histology 
**Excludes coverage for locoregional recurrence or symptomatic local disease (with the exception of mediastinal lymph node recurrence with prior radiation therapy) with no evidence of disseminated disease.

OVARIAN CANCER (EPITHELIAL), FALLOPIAN TUBE CANCER, OR PRIMARY PERITONEAL CANCER
  • In combination with carboplatin and paclitaxel, followed by bevacizumab or related biosimilar as a single agent for one of the following:
    • ​​​​In individuals who have not received prior chemotherapy and are experiencing rising CA-125 levels or clinical relapse, as NCCN-preferred therapy 
    • Poor surgical candidates or have low likelihood of optimal cytoreduction as NCCN-preferred therapy in:
      • neoadjuvant therapy
      • continued treatment for stable disease following neoadjuvant therapy
      • adjuvant therapy following interval debulking surgery (IDS) in individuals with response or stable disease to neoadjuvant therapy 
    • Primary adjuvant therapy for pathologic Stage II-IV disease with endometroid or serous histology, as NCCN-preferred therapy 
    • Adjuvant treatment for pathologic stage I-IV II-IV disease and carcinosarcoma histology, as NCCN-preferred therapy 
    • Adjuvant treatment for pathologic stage II-IV disease and clear cell histology, as NCCN-preferred therapy 
    • Adjuvant treatment for pathologic stage II-IV disease and mucinous histology, as NCCN-preferred therapy 
    • Adjuvant treatment for pathologic stage II-IV, grade 1 endometrioid carcinoma, as NCCN-preferred therapy 
    • Adjuvant treatment for pathologic stage II-IV low-grade serous carcinoma or borderline epithelial tumors with invasive implants as NCCN-preferred therapy
  • Maintenance therapy as a single agent if used previously as part of a combination therapy:
    • Partial or complete remission or stable disease following primary therapy for Stage II-IV disease
    • Partial or complete response following recurrence therapy with bevacizumab for platinum-sensitive disease
  • ​Maintenance therapy for stage II-IV disease if complete clinical remission (CR) or partial remission (PR) to primary therapy including bevacizumab
    • as ​a single agent or in combination with olaparib in individuals BRCA1/2 wild-type or unknown
    • in combination with olaparib in individuals ​with a germline or somatic BRCA1/2 mutation
  • Targeted therapy as a single agent for persistent disease or recurrence (not including biochemical relapse), as a NCCN-preferred​ therapy 
    • ​as immediate treatment for serially rising CA-125 in individuals that previously received chemotherapy
    • for progression on primary, maintenance, or recurrence therapy
    • for stable or persistent disease (if not on maintenance therapy)
    • for complete remission and relapse <6 months after completing chemotherapy
    • for radiographic and/or clinical relapse in individuals with previous complete remission and relapse after ≥6 months after completing prior chemotherapy
  • ​Targeted therapy in combination with niraparib in platinum-sensitive peristent disease or recurrence (not including biochemical relapse) 
    • ​as immediate treatment for serially rising CA-125 in individuals that previously received chemotherapy
    • for radiographic and/or clinical relapse in individuals with previous complete remission and relapse after ≥6 months after completing prior chemotherapy
  • Platinum-sensitive persistent disease or recurrence in individuals with carcinosarcoma, clear cell, endometrioid, mucinous, or serous histology​ (not including biochemical relapse) ​ 
    • For one of the following conditions: 
      • ​as immediate treatment for serially rising CA-125 in individuals that previously received chemotherapy
      • in individuals with complete remission and relapse ≥6 months after completing prior chemotherapy
    • ​​In combination with one of the following regimens:
      • carboplatin and ​gemcitabine (NCCN-preferred)
      • carboplatin and paclitaxel (NCCN-preferred)
      • carboplatin and liposomal doxorubicin (NCCN-preferred)
      • fluorouracil, leucovorin, and oxaliplatin for mucinous carcinoma
      • capecitabine and oxaliplatin for mucinous carcinoma
  • ​​​​​​​​Platinum-resistant persistent disease or recurrence in​ combination with oral cyclophosphamide, liposomal doxorubicin, weekly paclitaxel, or topotecan (not including biochemical relapse), as a NCCN-preferred​ therapy 
    • ​​as immediate treatment for serially rising CA-125 in individuals that previously received chemotherapy
    • for progression on primary, maintenance, or recurrence therapy
    • for stable or persistent disease (if not on maintenance therapy)
    • for complete remission and relapse <6 months after completing chemotherapy
  • ​​​In individuals who have malignant sex cord-stromal tumors (stage II-IV) as therapy for clinical relapse, as a single agent​ ​
SOFT TISSUE SARCOMA
  • In individuals with angiosarcoma as a single agent
  • In individuals with solitary fibrous tumor or hemangiopericytoma in combination with temozolomide, as NCCN-preferred therapy​. 
UTERINE CANCER/ENDOMETRIAL CANCER
  • As a single agent for disease that has progressed on prior cytotoxic chemotherapy
  • In combination with carboplatin and paclitaxel for advanced and recurrent disease
VULVAR CANCER
In combination with cisplatin and paclitaxel (NCCN-preferred regimen):
  • as additional treatment for unresectable locally advanced disease (larger T2, T3) clinically positive for residual tumor at the primary site and/or nodes
  • as additional treatment for locally advanced disease (larger T2, T3) with positive margins following resection
  • as primary treatment for metastatic disease beyond the pelvis (any T, any N, M1 beyond pelvis) ​
  • for isolated groin/pelvic inguinofemoral/pelvic lymph node recurrence if prior external beam radiation therapy (EBRT)
  • for clinical nodal or distant recurrence with multiple pelvic nodes, distant metastasis, or prior pelvic EBRT
NOT MEDICALLY NECESSARY

For individuals receiving their first course of bevacizumab, use of the non-preferred reference product bevacizumab (Avastin®) or any non-preferred biosimilar, is considered not medically necessary and, therefore, not covered unless the individual has documented contraindication(s) or intolerance(s) to the Company designated preferred products, since they are more costly than the preferred products that are at least as likely to produce equivalent therapeutic results for that individual's illness. 

EXPERIMENTAL/INVESTIGATIONAL

All other uses of bevacizumab and related biosimilars are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the medical policy on off-label coverage for prescription drugs and biologics.

DOSING AND FREQUENCY REQUIREMENTS

Refer to Attachment A for dosing and frequency requirements for bevacizumab and related biosimilars.

The Company reserves the right to modify the Dosing and Frequency Requirements listed in this Policy to ensure consistency with the most recently published recommendations for the use of bevacizumab and related biosimilars. Changes to these guidelines are based on a consensus of information obtained from resources such as, but not limited to: the US Food and Drug Administration (FDA); Company-recognized authoritative pharmacology compendia; or published peer-reviewed clinical research. The professional provider must supply supporting documentation (i.e., published peer-reviewed literature) in order to request coverage for an amount of bevacizumab and related biosimilars outside of the Dosing and Frequency Requirements listed in this Policy. For a list of Company-recognized pharmacology compendia, view our policy on off-label coverage for prescription drugs and biologics.

Accurate member information is necessary for the Company to approve the requested dose and frequency of this drug. If the member’s dose, frequency, or regimen changes (based on factors such as changes in member weight or incomplete therapeutic response), the provider must submit those changes to the Company for a new approval based on those changes as part of the precertification process. The Company reserves the right to conduct post-payment review and audit procedures for any claims submitted for bevacizumab and related biosimilars.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the drug.

When coverage of bevacizumab and related biosimilars is requested outside of the Dosing and Frequency Guidelines listed in this Policy, the prescribing professional provider must supply documentation (i.e., published peer-reviewed literature) to the Company that supports this request.

Guidelines

BLACK BOX WARNINGS

Refer to the specific manufacturer's prescribing information for any applicable Black Box Warnings.

THE EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) PERFORMANCE STATUS  

The ECOG has developed the ECOG Performance Status; it was originally published in 1982 in the American Journal of Clinical Oncology*. ECOG states, "These scales and criteria are used by doctors and researchers to assess how a patient's disease is progressing, assess how the disease affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. They are included here for health care professionals to access."
ECOG Performance Status
Grade
ECOG
0
Fully active, able to carry on all pre-disease performance without restriction
1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2
Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50 percent of waking hours
3
Capable of only limited self care, confined to bed or chair more than 50 percent of waking hours
4
Completely disabled. Cannot carry on any self care: Totally confined to bed or chair
5
Dead
*Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol.1982;5(6):649-655.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, bevacizumab and related biosimilars are covered under the medical benefits of the Company’s products when the medical necessity criteria, dosing and frequency requirements, and the precertification/preapproval requirements listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The initial approval for the use of bevacizumab was granted by the FDA on February 26, 2004. Supplemental approvals have since been issued. The safety, effectiveness and pharmacokinetic profile of bevacizumab in the pediatric population have not been established.

The FDA has issued subsequent approvals for biosimilar products.

Description

Bevacizumab and related biosimilars are recombinant humanized monoclonal IgG1 antibodies that work by binding to and inhibiting the action of vascular endothelial growth factor (VEGF). VEGF is a substance that binds to certain cells to stimulate new blood vessel formation (angiogenesis). When VEGF is bound to bevacizumab and related biosimilars, it cannot stimulate the formation and growth of new blood vessels. Bevacizumab and related biosimilars are thought to enhance the effects of chemotherapy.

The US Food and Drug Administration (FDA) has granted approval for the use of bevacizumab and related biosimilars for the following indications:
  • In individuals who have metastatic carcinoma of the colon or rectum, as first- or second-line treatment, in combination with intravenous 5-fluorouracil--based chemotherapy
  • In individuals who have metastatic carcinoma of the colon or rectum, as a second-line treatment in patients who have progressed on a first-line bevacizumab regimen, in combination with fluoropyrimidine-, irinotecan-, or fluoropyrimidine-oxaliplatin--based chemotherapy
    • In individuals who have unresectable, locally advanced, recurrent, or metastatic non-squamous non-small cell lung cancer, as first-line treatment in combination with paclitaxel (Taxol®) and carboplatin (Paraplatin®)
      • In individuals who have recurrent glioblastoma, as a single agent
        • In individuals who have metastatic renal cell carcinoma, in combination with interferon alfa
          • In individuals who have persistent, recurrent, or metastatic carcinoma of the cervix, in combination with paclitaxel and cisplatin or paclitaxel and topotecan​​
            • In individuals who have stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal cancer following initial surgical resection, in combination with carboplatin and paclitaxel, followed by bevacizumab as a single agent.
            • In individuals who have platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer who received no more than 2 prior chemotherapy regimens, in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan.
            • In individuals who have platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer when given either in combination with carboplatin and paclitaxel or in combination with carboplatin and gemcitabine, followed by bevacizumab as a single agent.
            • In individuals with unresectable or metastatic hepatocellular carcinoma (HCC) who have not received prior systemic therapy, in combination with atezolizumab (Tecentriq)​
            There may be additional indications contained in the Policy section of this document due to evaluation of criteria highlighted in the Company’s off-label policy, and/or review of clinical guidelines issued by leading professional organizations and government entities.

            In 2008, the FDA gave accelerated approval for the treatment of metastatic breast cancer. However in 2011, the FDA withdrew this indication, since further studies showed only a small delay in tumor growth compared to earlier trials, no increase in overall survival, and an increase in the incidence of serious adverse events. Considering all information from these studies, the FDA concluded that the risks of this drug outweighed its benefits in the treatment of patients with metastatic breast cancer. Although this indication was withdrawn from the FDA, drug compendia still support the use of bevacizumab for the treatment of metastatic breast cancer.

            References

            American Hospital Formulary Service (AHFS). Bevacizumab (Avastin®). Drug Information 2020. [Lexicomp Online Web site]. 09/22/16. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed November 23, 2020. 

            Bevacizumab (Avastin®) labeling. Genentech, Inc., South San Francisco, CA. 02/2019. Available at: https://www.avastin-hcp.com/ . Accessed November 18, 2020. 

            Eastern Cooperative Oncology Group (ECOG). ECOG performance status. Available at: http://ecog-acrin.org/resources/ecog-performance-status . Accessed November 23, 2020. 

            Elsevier’s Clinical Pharmacology Compendium. Bevacizumab (Avastin®), bevacizumab-awwb (Mvasi)bevacizumab-bvzr (Zirabev™). 10/13/2020. [Clinical Key Web site]. Available at: https://www.clinicalkey.com/pharmacology/monograph/2709?n=Avastin [via subscription only]. Accessed November 23, 2020. 

            Lexi-Drugs Compendium. bevacizumab (Avastin). 11/11/2020. [Lexicomp Online Web site]. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed November 23, 2020. 

            Mvasi (bevacizumab-awwb) labeling. Amgen Inc., Thousand Oaks, CA. 6/2019. Available at: https://www.mvasi.com/hcp. Accessed November 18, 2020. 

            National Cancer Institute (NCI). Ovarian epithelial, fallopian tube, and primary peritoneal cancer treatment (PDQ®). Health professional version. ​11/20/2020. [NCI Web site]. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/ovarianepithelial/HealthProfessional/page1 . Accessed November 23, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Breast cancer. v.6.2020. [NCCN Web site]. 09/08/2020. Available at: http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf. Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Central nervous system cancers. v.3.2020. [NCCN Web site]. 09/11/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf​. Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Cervical cancer. v.1.2021. [NCCN Web site]. 10/02/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Colon cancer. v.4.2020. [NCCN Web site]. 06/15/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Hepatobiliary cancers. v.5.2020. [NCCN Web site]. 08/04/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/hepatobiliary.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Kidney cancer. v.1.2021. [NCCN Web site]. 07/15/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf. Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Malignant Pleural Mesothelioma. v.2.2020. [NCCN Web site]. 10/15/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/mpm.pdf​ . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Non-small cell lung cancer. v.8.2020. [NCCN Web site]. 09/15/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Ovarian cancer, including fallopian tube cancer and primary peritoneal cancer. v.1.2020. [NCCN Web site]. 03/11/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf . Accessed  November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Rectal cancer. v.6.2020. [NCCN Web site]. 06/25/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Small bowel adenocarcinoma. v.2.2020. [NCCN Web site]. 05/06/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/small_bowel.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Soft Tissue Sarcoma. v.1.2021. [NCCN Web site]. 10/30/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf​ . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Uterine Neoplasms. v.1.2021. [NCCN Web site]. 10/20/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Vulvar cancer (Squamous cell carcinoma). v.2.2021. [NCCN Web site]. 10/19/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/vulvar.pdf . Accessed November 18, 2020. 

            National Comprehensive Cancer Network (NCCN). NCCN Drugs & Biologics Compendium™. Bevacizumab (Avastin®), bevacizumab-awwb (Mvasi)bevacizumab-bvzr (Zirabev™). 2020. [NCCN Web site]. Available at: http://www.nccn.org/professionals/drug_compendium/content/contents.asp [via subscription only]. Accessed November 18, 2020. 

            Pope WB, Lai A, Nghiemphu P, et al. MRI in patients with high-grade gliomas treated with bevacizumab and chemotherapy. Neurology. 2006;66(8):1258-1260.

            Salah Uddin ABM, Jarmi T. Neurologic Manifestations of Glioblastoma multiforme. [eMedicine Web site]. 10/09/2020. Available at: http://emedicine.medscape.com/article/1156220-overview . Accessed November 23, 2020. 

            Truven Health Analytics. Micromedex® DrugDex® Compendium. Bevacizumab (Avastin®), bevacizumab-awwb (Mvasi)bevacizumab-bvzr (Zirabev™). 11/12/2020. Greenwood Village, CO. [Micromedex® Solutions Web site]. Available at: http://www.micromedexsolutions.com/micromedex2/librarian/ [via subscription only]. Accessed November 23, 2020. 

            US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Avastin (bevacizumab). Package insert. [FDA Web site]. 10/09/2020. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/ . Accessed November 18, 2020. 

            US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Mvasi™(bevacizumab-awwb). Package insert. [FDA Web site]. 06/24/2019. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=761028 . Accessed November 18, 2020. 

            US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. bevacizumab-bvzr (Zirabev™). Package insert. [FDA Web site]. 06/27/2019. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/ . Accessed November 18, 2020. 

            US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Postmarket drug safety information for patients and providers. Questions and answers about avastin. 12/16/2010. Available at: https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm237095.htm . Accessed November 18, 2020. 

            Vredenburgh JJ, Desjardins A, Herndon JE 2nd, et al. Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clin Cancer Res. 2007;13(4):1253-1259.

            Zirabev (bevacizumab-bvzr) labeling. Pfizer Inc., NY, NY. 01/2020. Available at: https://www.zirabev.com/ . Accessed November 18, 2020. 

            Coding

            CPT Procedure Code Number(s)
            N/A

            ICD - 10 Procedure Code Number(s)
            N/A

            ICD - 10 Diagnosis Code Number(s)

            C18.0 Malignant neoplasm of cecum

            C18.1 Malignant neoplasm of appendix

            C18.2 Malignant neoplasm of ascending colon

            C18.3 Malignant neoplasm of hepatic flexure

            C18.4 Malignant neoplasm of transverse colon

            C18.5 Malignant neoplasm of splenic flexure

            C18.6 Malignant neoplasm of descending colon

            C18.7 Malignant neoplasm of sigmoid colon

            C18.8 Malignant neoplasm of overlapping sites of colon

            C18.9 Malignant neoplasm of colon, unspecified

            C19 Malignant neoplasm of rectosigmoid junction

            C20 Malignant neoplasm of rectum

            C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal

            C22.0 Liver cell carcinoma

            C22.1 Intrahepatic bile duct carcinoma

            C22.2 Hepatoblastoma

            C22.3 Angiosarcoma of liver

            C22.4 Other sarcomas of liver

            C22.7 Other specified carcinomas of liver

            C22.8 Malignant neoplasm of liver, primary, unspecified as to type

            C22.9 Malignant neoplasm of liver, not specified as primary or secondary

            C33 Malignant neoplasm of trachea

            C34.00 Malignant neoplasm of unspecified main bronchus

            C34.01 Malignant neoplasm of right main bronchus

            C34.02 Malignant neoplasm of left main bronchus

            C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

            C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

            C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

            C34.2 Malignant neoplasm of middle lobe, bronchus or lung

            C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

            C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

            C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

            C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

            C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

            C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

            C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

            C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

            C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

            C45.0 Mesothelioma of pleura

            C48.0 Malignant neoplasm of retroperitoneum

            C48.1 Malignant neoplasm of specified parts of peritoneum

            C48.2 Malignant neoplasm of peritoneum, unspecified

            C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum

            C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck

            C49.10 Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder

            C49.11 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder

            C49.12 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder

            C49.20 Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip

            C49.21 Malignant neoplasm of connective and soft tissue of right lower limb, including hip

            C49.22 Malignant neoplasm of connective and soft tissue of left lower limb, including hip

            C49.3 Malignant neoplasm of connective and soft tissue of thorax

            C49.4 Malignant neoplasm of connective and soft tissue of abdomen

            C49.5 Malignant neoplasm of connective and soft tissue of pelvis

            C49.6 Malignant neoplasm of connective and soft tissue of trunk, unspecified

            C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue

            C49.9 Malignant neoplasm of connective and soft tissue, unspecified

            C50.011 Malignant neoplasm of nipple and areola, right female breast

            C50.012 Malignant neoplasm of nipple and areola, left female breast

            C50.019 Malignant neoplasm of nipple and areola, unspecified female breast

            C50.021 Malignant neoplasm of nipple and areola, right male breast

            C50.022 Malignant neoplasm of nipple and areola, left male breast

            C50.029 Malignant neoplasm of nipple and areola, unspecified male breast

            C50.111 Malignant neoplasm of central portion of right female breast

            C50.112 Malignant neoplasm of central portion of left female breast

            C50.119 Malignant neoplasm of central portion of unspecified female breast

            C50.121 Malignant neoplasm of central portion of right male breast

            C50.122 Malignant neoplasm of central portion of left male breast

            C50.129 Malignant neoplasm of central portion of unspecified male breast

            C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

            C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

            C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast

            C50.221 Malignant neoplasm of upper-inner quadrant of right male breast

            C50.222 Malignant neoplasm of upper-inner quadrant of left male breast

            C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast

            C50.311 Malignant neoplasm of lower-inner quadrant of right female breast

            C50.312 Malignant neoplasm of lower-inner quadrant of left female breast

            C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast

            C50.321 Malignant neoplasm of lower-inner quadrant of right male breast

            C50.322 Malignant neoplasm of lower-inner quadrant of left male breast

            C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast

            C50.411 Malignant neoplasm of upper-outer quadrant of right female breast

            C50.412 Malignant neoplasm of upper-outer quadrant of left female breast

            C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast

            C50.421 Malignant neoplasm of upper-outer quadrant of right male breast

            C50.422 Malignant neoplasm of upper-outer quadrant of left male breast

            C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast

            C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

            C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

            C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast

            C50.521 Malignant neoplasm of lower-outer quadrant of right male breast

            C50.522 Malignant neoplasm of lower-outer quadrant of left male breast

            C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast

            C50.611 Malignant neoplasm of axillary tail of right female breast

            C50.612 Malignant neoplasm of axillary tail of left female breast

            C50.619 Malignant neoplasm of axillary tail of unspecified female breast

            C50.621 Malignant neoplasm of axillary tail of right male breast

            C50.622 Malignant neoplasm of axillary tail of left male breast

            C50.629 Malignant neoplasm of axillary tail of unspecified male breast

            C50.811 Malignant neoplasm of overlapping sites of right female breast

            C50.812 Malignant neoplasm of overlapping sites of left female breast

            C50.819 Malignant neoplasm of overlapping sites of unspecified female breast

            C50.821 Malignant neoplasm of overlapping sites of right male breast

            C50.822 Malignant neoplasm of overlapping sites of left male breast

            C50.829 Malignant neoplasm of overlapping sites of unspecified male breast

            C50.911 Malignant neoplasm of unspecified site of right female breast

            C50.912 Malignant neoplasm of unspecified site of left female breast

            C50.919 Malignant neoplasm of unspecified site of unspecified female breast

            C50.921 Malignant neoplasm of unspecified site of right male breast

            C50.922 Malignant neoplasm of unspecified site of left male breast

            C50.929 Malignant neoplasm of unspecified site of unspecified male breast

            C51.0 Malignant neoplasm of labium majus

            C51.1 Malignant neoplasm of labium minus

            C51.2 Malignant neoplasm of clitoris

            C51.8 Malignant neoplasm of overlapping sites of vulva

            C51.9 Malignant neoplasm of vulva, unspecified

            C51.8 Malignant neoplasm of overlapping sites of vulva

            C51.9 Malignant neoplasm of vulva, unspecified

            C53.0 Malignant neoplasm of endocervix

            C53.1 Malignant neoplasm of exocervix

            C53.8 Malignant neoplasm of overlapping sites of cervix uteri

            C53.9 Malignant neoplasm of cervix uteri, unspecified

            C54.0 Malignant neoplasm of isthmus uteri

            C54.1 Malignant neoplasm of endometrium

            C54.2 Malignant neoplasm of myometrium

            C54.3 Malignant neoplasm of fundus uteri

            C54.8 Malignant neoplasm of overlapping sites of corpus uteri

            C54.9 Malignant neoplasm of corpus uteri, unspecified

            C55 Malignant neoplasm of uterus, part unspecified

            C56.1 Malignant neoplasm of right ovary

            C56.2 Malignant neoplasm of left ovary

            C56.9 Malignant neoplasm of unspecified ovary

            C57.00 Malignant neoplasm of unspecified fallopian tube

            C57.01 Malignant neoplasm of right fallopian tube

            C57.02 Malignant neoplasm of left fallopian tube

            C57.10 Malignant neoplasm of unspecified broad ligament

            C57.11 Malignant neoplasm of right broad ligament

            C57.12 Malignant neoplasm of left broad ligament

            C57.20 Malignant neoplasm of unspecified round ligament

            C57.21 Malignant neoplasm of right round ligament

            C57.22 Malignant neoplasm of left round ligament

            C57.3 Malignant neoplasm of parametrium

            C57.4 Malignant neoplasm of uterine adnexa, unspecified

            C57.8 Malignant neoplasm of overlapping sites of female genital organs

            C64.1 Malignant neoplasm of right kidney, except renal pelvis

            C64.2 Malignant neoplasm of left kidney, except renal pelvis

            C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis

            C65.1 Malignant neoplasm of right renal pelvis

            C65.2 Malignant neoplasm of left renal pelvis

            C65.9 Malignant neoplasm of unspecified renal pelvis

            C70.0 Malignant neoplasm of cerebral meninges

            C70.1 Malignant neoplasm of spinal meninges

            C70.9 Malignant neoplasm of meninges, unspecified

            C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles

            C71.1 Malignant neoplasm of frontal lobe

            C71.2 Malignant neoplasm of temporal lobe

            C71.3 Malignant neoplasm of parietal lobe

            C71.4 Malignant neoplasm of occipital lobe

            C71.5 Malignant neoplasm of cerebral ventricle

            C71.6 Malignant neoplasm of cerebellum

            C71.7 Malignant neoplasm of brain stem

            C71.8 Malignant neoplasm of overlapping sites of brain

            C71.9 Malignant neoplasm of brain, unspecified

            C72.0 Malignant neoplasm of spinal cord

            C78.00 Secondary malignant neoplasm of unspecified lung

            C78.01 Secondary malignant neoplasm of right lung

            C78.02 Secondary malignant neoplasm of left lung

            C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum

            C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct​​




            HCPCS Level II Code Number(s)

            C9257 Injection, bevacizumab, 0.25 mg

            J9035 Injection, bevacizumab, 10 mg

            Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg

            Q5118 Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg


            Revenue Code Number(s)
            N/A

            Modifiers



            Coding and Billing Requirements

            BILLING REQUIREMENTS

            If there is no specific HCPCS code available for the drug administered, then the drug must be reported with the most appropriate unlisted code along with the corresponding National Drug Code (NDC).

            Policy History

            1/18/2021
            1/18/2021
            08.00.66
            Medical Policy Bulletin
            Commercial
            {"2985": {"Id":2985,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":5036,"PolicyAttachmentPageName":"98bfbb87-d5a2-44b4-a5ef-b1b180d98102"},}
            No