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Avelumab (Bavencio®)
08.01.64c

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

GESTATIONAL TROPHOBLASTIC NEOPLASIA 
Avelumab (Bavencio®) is considered medically necessary and, therefore, covered for adult individuals as a single agent for multiagent chemotherapy-resistant disease in either of the following:
  • High-risk disease
  • Recurrent or progressive intermediate trophoblastic tumor (placental site trophoblastic tumor or epithelioid trophoblastic tumor) ​
MERKEL CELL CARCINOMA ​(MCC)
Avelumab (Bavencio) is considered medically necessary and, therefore, covered in adult and pediatric individuals 12 years and older with metastatic (M1 disseminated disease) Merkel cell carcinoma with or without surgery and/or radiation therapy (National Comprehensive Cancer Network [NCCN] preferred regimen).

RENAL CELL CARCINOMA (RCC)
Avelumab (Bavencio) in combination with axitinib is considered medically necessary and, therefore, covered for ​adult individuals with advanced RCC as first-line therapy for relapse or stage IV disease and clear cell histology.​

UROTHELIAL CARCINOMA (UC)
Avelumab (Bavencio) is considered medically necessary and, therefore, covered as single-agent therapy for the treatment of adult individuals for one of the following indications:
  • Locally advanced or metastatic UC ​in individuals with disease progression, in one of the following scenarios:
    • During or post–​platinum-containing chemotherapy
    • Within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy
  • ​Locally advanced or metastatic UC as single-agent maintenance therapy if there is no progression on first-line platinum-containing chemotherapy that consisted of any of the following regimens:
    • ​Gemcitabine and cisplatin (NCCN preferred)
    • ​Gemcitabine and carboplatin
    • ​DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, cisplatin) (NCCN preferred)​
  • Recurrent or metastatic primary carcinoma​ of the urethra that is not recurrent stage T3-4 disease and is without palpable inguinal lymph nodes, as a single-agent, second-line systemic therapy, post-platinum or other chemotherapy (NCCN alternative preferred)
  • Metastatic UC of the prostate or metastatic upper genitourinary tract (GU) tumors, as a single-agent, second-line systemic therapy, post-platinum or other chemotherapy (NCCN alternative preferred),
  • Locally advanced or metastatic bladder cancer, as a single-agent (NCCN preferred), second-line systemic therapy, post-platinum or other chemotherapy, in any of the following clinical stages:
    • Stage II (cT2, N0) disease or stage IIIA (cT3, N0; cT4a, N0; cT1-T4a, N1) disease if tumor is present following reassessment of tumor status 2 to 3 months after primary treatment with concurrent bladder-preserving chemoradiotherapy and maximal transurethral resection of bladder tumor (TURBT)​​
    • Stage IIIB (​cT1-T4a, N2,3) disease following partial response or progression after primary treatment with downstaging systemic therapy or concurrent chemoradiotherapy
    • Stage IVA (​cT4b, any N, M0) disease if tumor is present following reassessment of tumor status after primary treatment with first-line systemic therapy or concurrent chemoradiotherapy
    • Stage IVA (any T, any N, M1a) disease if stable disease or progression following reassessment of tumor status after primary treatment with first-line systemic therapy
    • Metastatic stage IVB (any T, any N, M1b) disease
    • Muscle invasive local recurrence or persistent disease in a preserved bladder treated with curative intent
    • Metastatic or local recurrence post-cystectomy treated with curative intent
UTERINE NEOPLASMS
Avelumab (Bavencio) is considered medically necessary and, therefore, covered for adult individuals with endometrial carcinoma (i.e., serous carcinoma, clear cell carcinoma, carcinosarcoma, endometrioid adenocarcinoma, undifferentiated/dedifferentiated carcinoma histology types), as a single-agent second-line or subsequent treatment for recurrent, or metastatic,​ microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) tumors in one of the following:
  • Isolated metastases
  • Disseminated metastases with or without sequential palliative external beam radiation therapy (EBRT)
  • With sequential EBRT and with or without brachytherapy for locoregional recurrence in individuals with no prior radiation therapy (RT) to site of recurrence, or previous brachytherapy only
  • After surgical exploration, with sequential EBRT for locoregional recurrence in individuals with disease confined to the vagina or paravaginal soft tissue, or in pelvic, para-aortic or common iliac lymph nodes
  • After surgical exploration, with or without sequential EBRT for locoregional recurrence in individuals with upper abdominal or peritoneal disease
  • With or without sequential palliative EBRT or brachytherapy for locoregional recurrence in individuals who have received prior EBRT to site of recurrence​

​EXPERIMENTAL/INVESTIGATIONAL

All other uses for avelumab (Bavencio) are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the Company medical policy on Off-label Coverage for Prescription Drugs and Biologics.

MANDATES

PENNSYLVANIA MEMBERS
In accordance with the Commonwealth of Pennsylvania's Act 6 of 2020 or Fair Access to Cancer Treatment Act, for members who are enrolled in Pennsylvania commercial products who have Stage 4, advanced metastatic cancer, refer to the Medical Policy titled "Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents” (08.01.08) for additional information regarding the applicable coverage of drugs and biologics.

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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, avelumab (Bavencio) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

THE EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) PERFORMANCE STATUS

The Eastern Cooperative Oncology Group (ECOG), established in 1955, was one of the first groups to coordinate multicenter cancer clinical trials. The National Cancer Institute (NCI) is the primary funding source, and ECOG has evolved from a small consortium of institutions in the eastern United States to one of the largest clinical cancer research organizations in the country. As part of their work in the treatment of cancer, ECOG has developed the ECOG Performance Status (EPS), originally published in 1982 in the American Journal of Clinical Oncology. The use of the scales and the criteria in the EPS allows clinicians and researchers to determine an individual’s disease progression in terms of how the activities of daily living (ADL) are affected.
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 (eg, light housework, 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.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Avelumab (Bavencio) was approved by the FDA on March 23, 2017, for the treatment of adult and pediatric individuals ages 12 years and older with metastatic Merkel cell carcinoma. Supplemental approvals for avelumab (Bavencio) have since been issued by the FDA. Avelumab (Bavencio) is administered as an intravenous infusion over 60 minutes.

PEDIATRIC USE
The safety and effectiveness of avelumab (Bavencio​) have not been established in pediatric individuals for indications other than metastatic Merkel cell carcinoma.

Description

In a normal immune response, the body can recognize the presence of tumors and mount a response to eradicate them. The process of eradicating a tumor begins with antigen-presenting cells that gather and process the antigens released by tumors. This activates the T cells, which proliferate and attack the tumor.

Tumors have learned to evade the normal immune response by exploiting the immune checkpoint pathway. The Programmed Death Receptor-1 (PD-1) is a checkpoint protein expressed on the membrane of activated T cells. The Programmed Death-Ligand 1 (PD-L1) and the Programmed Death-Ligand 2 (PD-L2) are checkpoint proteins expressed on tumor cells and tumor-infiltrating immune cells. When PD-L1 and PD-L2 attach to PD-1 receptors on the T cells, the T cells become inhibited and will not attack the tumor; thus, the tumor can continue to proliferate. Avelumab (Bavencio) is a PD-L1 blocker. The drug acts by stopping the ligands from attaching to the PD-1 receptor and thus allowing the T cells to recognize the tumor and attack it.

MERKEL CELL CARCINOMA (MCC)

Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer with an incidence of approximately 1,500 cases per year in the United States, with 12 ​percent of these cases presenting at stage 4. Merkel cell carcinoma has a high mortality rate, with a 5-year survival of only 30 ​percent ​to 64 percent. Common sites of metastasis are the lymph nodes and distant skin sites.

On March 23, 2017, the US Food and Drug Administration (FDA) granted approval for avelumab (Bavencio) for the treatment of adult and pediatric individuals 12 years and older with metastatic MCC. The safety and efficacy of avelumab (Bavencio) was demonstrated in the JAVELIN Merkel 200 trial (NCT02155647), a phase 2, open-label, single-arm, multicenter study conducted in individuals with histologically confirmed metastatic MCC whose disease had progressed on or after chemotherapy administered for distant metastatic disease. The trial excluded individuals with autoimmune disease; medical conditions requiring systemic immunosuppression; prior organ or allogeneic stem cell transplantation; prior treatment with anti-PD-1, anti-PD-L1, or anticytotoxic T lymphocyte–associated antigen-4​ (CTLA-4) antibodies; central nervous system (​CNS) metastases; infection with human immunodeficiency virus (​HIV), hepatitis B, or hepatitis C; or Eastern Cooperative Oncology Group (ECOG) performance score ​​(PS) greater than 1.

Study participants received avelumab (Bavencio), 10 mg/kg, as an intravenous (IV) infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. Individuals with radiological disease progression not associated with significant clinical deterioration, defined as no new or worsening symptoms, no change in performance status for greater than 2 weeks, and no need for salvage therapy, could continue treatment. Tumor response assessments were performed every 6 weeks. The major efficacy outcome measures were confirmed overall response rate (ORR) according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 as assessed by a blinded independent central review ​(BICR) and BICR-assessed duration of response (DOR). To note, RECIST provides a standardized set of rules for response assessment using tumor shrinkage, based on imaging modalities that are globally available and interpretable by most clinicians. This standardization, and the rules and criteria established, provide a framework for reproducible analysis and reporting of changes in tumor size. The reproducibility of these criteria and the correlations with historical trial results serve an important purpose in drug discovery. The efficacy analysis was conducted when the last patient enrolled had completed 12 months of follow-up.

A total of 88 individuals were enrolled. Baseline characteristics were a median age of 73 years (range, 33 to 88), and the PS was 0 (56 percent) or 1 (44 percent). Seventy-five percent of individuals were 65 years or older, 35 percent were 75 or older, and three percent were 85 or older. Sixty-five percent of individuals were reported to have had one prior anticancer therapy for metastatic MCC and 35 percent had two or more prior therapies. Fifty-three percent of individuals had visceral metastases. All individuals had tumor samples evaluated for PD-L1 expression; of these, 66 percent were PD-L1–positive (1 percent​ or greater of tumor cells), 18 percent were PD-L1 negative, and 16 percent had nonevaluable results by an investigational immunohistochemistry assay. Archival tumor samples were evaluated for Merkel cell polyomavirus (MCV) using an investigational assay; of the 77 individuals with evaluable results, 52 percent had evidence of MCV.

The study showed an ORR of 33 percent (95 percent confidence interval [CI], 23.3–43.8). Eleven percent of individuals experienced a complete response (95 percent CI, 6.6–19.9), and 22 percent of individuals experienced a partial response (95 percent CI, 13.5–31.7). Tumor responses were durable, with 86 percent of responses lasting for at least 6 months (n=25). Forty-five percent of responses lasted at least 12 months (n=13). DOR ranged from 2.8 to over 23.3 months.

This indication is approved under accelerated approval based on tumor response rate and DOR. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

RENAL CELL CARCINOMA (RCC) 

In adults, renal cell carcinoma (RCC) accounts for 80 percent ​to 95 percent of all primary kidney cancers. When diagnosed, 65 percent of individuals have localized disease confined to the kidney. At 75 percent ​to 85 percent, the clear cell subtype of RCC accounts for the highest percentage among other subtypes of the disease.

The efficacy and safety of avelumab (Bavencio) in combination with axitinib was demonstrated in the JAVELIN Renal 101 trial (NCT02684006), a phase 3, randomized, multicenter, open-label study of avelumab (Bavencio) in combination with axitinib in 886 individuals with untreated advanced RCC regardless of tumor PD-L1 expression (intent-to-treat [ITT] population). Individuals with autoimmune disease or conditions requiring systemic immunosuppression were excluded.

Randomization was stratified according to PS (0 v​s 1) and region (United States v​s Canada/Western Europe v​s the rest of the world). Participants were randomly assigned (1:1) to one of the following treatment arms:
  • Avelumab (Bavencio), 10 mg/kg IV every 2 weeks in combination with axitinib, 5 mg twice daily orally (N=442). Individuals who tolerated axitinib 5 mg twice daily without grade 2 or greater axitinib-related adverse events for 2 consecutive weeks could increase to 7 mg and then subsequently to 10 mg twice daily. Axitinib could be interrupted or reduced to 3 mg twice daily and subsequently to 2 mg twice daily to manage toxicity.
  • Sunitinib, 50 mg once daily orally for 4 weeks followed by 2 weeks off (N=444) until radiographic or clinical progression or unacceptable toxicity
Treatment with avelumab (Bavencio) and axitinib continued until RECIST 1.1 defined progression of disease by BICR assessment or unacceptable toxicity. Administration of avelumab (Bavencio) and axitinib was permitted beyond RECIST-defined disease progression if the patient was clinically stable and considered to be deriving clinical benefit by the investigator. Assessment of tumor status was performed at baseline, after randomization at 6 weeks, then every 6 weeks thereafter up to 18 months after randomization, and every 12 weeks thereafter until documented confirmed disease progression by BICR.

Baseline characteristics were a median age of 61 years (range, 27–88), 38 percent of individuals were 65 years or older, and the PS was 0 (63 percent) or 1 (37 percent), respectively. Individual distribution by International Metastatic Renal Cell Carcinoma Database (IMDC) risk groups was 21 percent favorable, 62 percent intermediate, and 16 percent poor.

The major efficacy outcome measures were progression-free survival (PFS), as assessed by a BICR using RECIST 1.1 and overall survival (OS) in individuals with PD-L1–positive tumors using a clinical trial assay (PD-L1 expression level ​one percent​ or greater). Because PFS was statistically significant in individuals with PD-L1–positive tumors (HR, 0.61 [95 percent CI, 0.48–0.79]), it was then tested in the ITT population and a statistically significant improvement in PFS in the ITT population was also demonstrated.

Among individuals with previously untreated advanced RCC, treatment with avelumab (Bavencio) plus axitinib continued to result in a statistically significant improvement in PFS versus sunitinib; OS data were still immature.

UROTHELIAL CARCINOMA (UC)

The urinary tract is composed of the renal pelvis, ureters, bladder, and urethra. The innermost lining of the urinary tract is composed of urothelial cells. UC, also known as transitional cell carcinoma (TCC), is the ninth most common cancer overall worldwide and it accounts for 90 percent of all bladder cancers. Squamous cell carcinoma comprises 1 percent ​to 7 percent of upper tract urothelial tumors. Adenocarcinoma accounts for less than 1 percent​ of upper tract tumors. Urothelial tumors of the renal pelvis and ureters are rare. Tumors of the renal pelvis account for approximately 5 percent of all urothelial tumors of the urinary tract.

On May 9, 2017, avelumab (Bavencio) was approved by the FDA for the treatment of individuals with locally advanced or metastatic UC who have disease progression during or following platinum-containing chemotherapy, or who have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

The efficacy and safety of avelumab (Bavencio) was demonstrated in the UC cohorts of the JAVELIN Solid Tumor trial (NCT01772004)​, an open-label, single-arm, multicenter study that included 242 individuals with locally advanced or metastatic UC with disease progression on or after platinum-containing chemotherapy or who had disease progression within 12 months of treatment with a platinum-containing neoadjuvant or adjuvant chemotherapy regimen. Individuals with active or history of CNS metastasis; other malignancies within the last 5 years; organ transplant; conditions requiring therapeutic immune suppression; or active infection with HIV, hepatitis B, or hepatitis C were excluded. Individuals with autoimmune disease, other than type 1 diabetes, vitiligo, psoriasis, or thyroid disease that did not require immunosuppressive treatment, were excluded. Individuals were included regardless of their PD-L1 status.

Study participants received avelumab (Bavencio) at a dose of 10 mg/kg IV every 2 weeks until radiographic or clinical progression or unacceptable toxicity. Tumor response assessments were performed every 6 weeks. Efficacy outcome measures included confirmed ORR as assessed by a BICR using RECIST 1.1 and DOR. Efficacy was evaluated in individuals who were followed for a minimum of both 13 weeks and 6 months at the time of data cut-off.

Baseline demographic and disease characteristics for the 226 individuals with a minimum of 13 weeks of follow-up were median age 68 years (range, 30–89), and 66 percent of individuals had a ​PS 0 or 1. Forty-four percent of individuals had nonbladder UC including 23 percent of individuals with upper tract disease, and 83 percent of individuals had visceral metastases (baseline target and/or nontarget lesions present outside of the lymph nodes). Nine individuals (4 percent) had disease progression following prior platinum-containing neoadjuvant or adjuvant therapy only. Forty-seven percent of individuals only received prior cisplatin-based regimens, 32 percent received only prior carboplatin-based regimens, and 20 percent received both cisplatin and carboplatin-based regimens. At baseline, 17 percent of individuals had a hemoglobin less than 10 g/dL and 34 percent of individuals had liver metastases.

The median time to response was 2.0 months (range,1.3–​11.0) among individuals followed for greater than 13 weeks or greater than 6 months. Using a clinical trial assay to assess PD-L1 staining, with 16 percent of individuals not evaluable, there were no clear differences in response rates based on PD-L1 tumor expression. Among the total 30 responding individuals followed for greater than 13 weeks, 22 individuals (73 percent) had an ongoing response of 6 months or longer and ​four individuals (13 percent) had ongoing responses of 12 months or longer. Among the total 26 responding individuals followed for greater than 6 months, 22 individuals (85 percent​) had ongoing responses of 6 months or longer and ​four individuals (15 percent) had ongoing responses of 12 months or longer.

OFF-LABEL INDICATIONS

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.

References

American Cancer Society. Bladder cancer. [American Cancer Society Web site]. Available at: https://www.cancer.org/cancer/types/bladder-cancer.html. Accessed November 16, 2023.

American Hospital Formulary Service (AHFS). Avelumab (Bavencio®). AHFS Drug Information 2023. [Lexicomp Web site]. 04/21/2023. Available at: https://online.lexi.com/lco/action/home [via subscription only]. Accessed November 16, 2023.

Avelumab (Bavencio®). Package insert. Rockland, MA: EMD Serono, Inc. 09/2023. Available at: https://www.bavencio.com/hcp. Accessed November 16, 2023.

Bellmunt J. Treatment of metastatic urothelial cancer of the bladder and urinary tract. [UpToDate Web site]. 10/26/2023. Available at: https://www.uptodate.com/contents/treatment-of-metastatic-urothelial-cancer-of-the-1bladder-and-urinary-tract​ [via subscription only]. Accessed November 16, 2023.

ClinicalTrials.gov. A study of avelumab in patients with locally advanced or metastatic urothelial cancer (JAVELIN Bladder 100). ClinicalTrials.gov Identifier: NCT02603432. First Posted: November 11, 2015. Last Update Posted: June 6, 2023. Available at: https://clinicaltrials.gov/. Accessed November 16, 2023.

ClinicalTrials.gov. A study of avelumab with axitinib versus sunitinib in advanced renal cell carcinoma (JAVELIN Renal 101). ClinicalTrials.gov Identifier: NCT02684006. First Posted: February 17, 2016. Last Update Posted November 9, 2023. Available at: https://clinicaltrials.gov/. Accessed November 16, 2023.

ClinicalTrials.gov. Avelumab in chemo-resistant gestational trophoblastic neoplasias (TROPHIMMUN). ClinicalTrials.gov Identifier: NCT03135769. First Posted: May 1, 2017. Last Update Posted: September 2, 2021. Available at: https://clinicaltrials.gov/. Accessed November 16, 2023.

ClinicalTrials.gov. Avelumab in metastatic or locally advanced solid tumors (JAVELIN Solid Tumor). ClinicalTrials.gov Identifier: NCT01772004. First Posted: January 21, 2013. Last Update Posted: December 20, 2021. Available at: https://clinicaltrials.gov/. Accessed November 16, 2023.

ClinicalTrials.gov. Avelumab in participants with Merkel cell carcinoma (JAVELIN Merkel 200). ClinicalTrials.gov Identifier: NCT02155647. First Posted: June 4, 2014. Last Update Posted: June 5, 2023. Available at: https://clinicaltrials.gov/. Accessed November 16, 2023.

D’Angelo SP, Bhatia S, Brohl AS, et al. Avelumab in patients with previously treated metastatic Merkel cell carcinoma: long-term data and biomarker analyses from the single-arm phase 2 JAVELIN Merkel 200 trial. J Immunother Cancer. 2020;8(1):e000674.

D’Angelo SP, Lebbe C, Mortier L, et al. First-line avelumab in a cohort of 116 patients with metastatic Merkel cell carcinoma (JAVELIN Merkel 200): primary and biomarker analyses of a phase II study. J Immunother Cancer. 2021;9(7):e002646.

Elsevier Clinical Pharmacology Compendium. Avelumab (Bavencio®). [MD Consult Web site]. 12/30/2020. Available at: https://www.clinicalkey.com/#!/ [via subscription only]. Accessed November 16, 2023. 

Konstantinopoulos PA, Luo W, Liu JF, et al. Phase II study of avelumab in patients with mismatch repair deficient and mismatch repair proficient recurrent/persistent endometrial cancer. J Clin Oncol. 2019;37(30)2786-2794.

Lexi-Drugs Compendium. Avelumab (Bavencio®). [Lexicomp Web site]. 09/20/2023. Available at: https://online.lexi.com/lco/action/home [via subscription only]. Accessed November 16, 2023.

Merative Micromedex® DRUGDEX® (electronic version). Avelumab (Bavencio®). [Micromedex Web site]. Merative L.P., Ann Arbor, Michigan, USA. 09/14/2023. Available at: https://www.micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed November 16, 2023.

Motzer RJ, Penkov K, Haanen J, et al. Avelumab plus axitinib versus sunitinib for advanced renal-cell carcinoma. N Engl J Med. 2019;380(12):1103-1115.

National Cancer Institute (NCI). Endometrial cancer treatment. [Cancer.gov Web site]. 03/13/2023. Available at: https://www.cancer.gov/types/uterine/hp/endometrial-treatment-pdq. Accessed November 16, 2023.

National Cancer Institute (NCI). Gestational trophoblastic disease treatment. [Cancer.gov Web site]. 10/20/2022. Available at: https://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq. Accessed November 16, 2023.

National Cancer Institute (NCI). NCI dictionary of cancer terms. RECIST. [Cancer.gov Web site]. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/recist#:~:text=A standard way to measure,CT scans, or MRI scans. Accessed November 16, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Bladder cancer. V3.2023. [NCCN Website]. 05/25/2023. Available at: https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf [via free subscription only]. Accessed November 16, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Gestational Trophoblastic Neoplasia. V1.2023. [NCCN Web site]. 12/20/2022. Available at: https://www.nccn.org/professionals/physician_gls/pdf/gtn.pdf.  [via free subscription only]. Accessed November 16, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Kidney Cancer. V1.2024. [NCCN Web site]. 06/21/2023. Available at:
https://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf [via free subscription only]. Accessed November 16, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Merkel Cell Carcinoma. V1.2023. [NCCN Web site]. 04/10/2023. Available at: https://www.nccn.org/professionals/physician_gls/pdf/mcc.pdf [via free subscription]. Accessed November 16, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Uterine Neoplasms. V1.2024. [NCCN Web site]. 09/20/2023. Available at: https://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf [via free subscription only]. Accessed November 16, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Drugs & Biologics Compendium®​. Avelumab (Bavencio®). [NCCN Web site]. Available at: https://www.nccn.org/professionals/drug_compendium/content/. Accessed November 16, 2023.

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.

Powles T, Park SH, Voog E, et al. Avelumab maintenance therapy for advanced or metastatic urothelial carcinoma. N Engl J Med. 2020;383(13):1218-1230.

Sachdeva K. Renal cell carcinoma. [Medscape Web site]. 03/21/2023. Available at: https://emedicine.medscape.com/article/281340-overview#showall. Accessed November 16, 2023.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Avelumab (Bavencio®) Prescribing information. [FDA Web site]. 09/06/2023. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm. Accessed November 16, 2023.

You B, Bolze PA, Lotz JP, et al. Avelumab in patients with gestational trophoblastic tumors with resistance to single-agent chemotherapy: cohort A of the TROPHIMMUN phase II trial. J Clin Oncol. 2020;38:3129-3137.​​​​​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment A.
HCPCS Level II Code Number(s)

J9023 Injection, avelumab, 10 mg​



Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

1/2/2024
1/8/2024
08.01.64
Medical Policy Bulletin
Commercial
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No
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