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Blinatumomab (Blincyto®)
MA08.058f

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

Blinatumomab (Blincyto) is considered medically necessary and, therefore, covered for individuals with ​acute lymphoblastic leukemiaeukemia who meet any of the following criteria, including Dosing and Frequency Requirements:

MINIMAL RESIDUAL DISEASE–POSITIVE (MRD+) ​DISEASE    
  • CD19-positive B-cell precursor acute lymphoblastic leukemia (B-ALL) in adult or pediatric individuals in first or second complete remission with minimal residual disease (MRD) greater than or equal to 0.1% 
  • Philadelphia chromosome (Ph-negative or Ph-like B-ALL in pediatric individuals who are MRD+ after consolidation therapy
  • Ph-positive B-ALL in pediatric individuals with less than complete response or MRD+ at end of consolidation​​
MINIMAL RESIDUAL DISEASE–NEGATIVE (MRD-) DISEASE ​    ​
  • Consolidation with a TKI* for Ph-positive B-ALL in individuals​ with negative MRD following a complete response to induction therapy in those who are not candidates for multiagent chemotherapy
MINIMAL RESIDUAL DISEASE–NEGATIVE (MRD-) ​OR MRD-UNAVAILABLE DISEASE ​    ​
  • Consolidation as a single agent for Ph-negative B-ALL in individuals​ with negative MRD or MRD unavailable following a complete response (CR) to induction therapy in individuals induced with inotuzumab ozogamicin + mini-hyperCVD (mini-hyper fractionated cyclophosphamide, vincristine, and dexamethasone, alternating with methotrexate and cytarabine), or in individuals ​for whom multiagent chemotherapy is contraindicated 
  • Maintenance in Ph-negative ALL in individuals​ as a single agent alternating with POMP (prednisone, vincristine, methotrexate, and mercaptopurine) in individuals with negative MRD or MRD unavailable after complete response to induction therapy with inotuzumab ozogamicin + mini-hyperCVD
PERSISTENT/RISING MINIMAL RESIDUAL DISEASE (MRD) 
  • Consolidation with or without a TKI* for Ph-positive B-ALL in individuals​ with persistent/rising MRD following a CR to induction therapy†​
  • ​Consolidation as a single agent for Ph-negative B-ALL in individuals​ with persistent/rising MRD following a CR to induction therapy​
RELAPSED OR REFRACTORY DISEASE     
  • Relapsed or refractory Ph-negative CD19-positive B-ALL in pediatric and adult individuals ​as a single agent (National Comprehensive Cancer Network (NCCN)-preferred regimen in adults)  
  • Relapsed or refractory Ph-positive CD19-positive B-ALL in individuals who are intolerant to or refractory to TKI* therapies or for relapsed or refractory Ph-negative B-ALL, as a component of inotuzumab ozogamicin + mini-hyperCVD + blinatumomab​​​​
  • Relapsed or refractory Ph-positive CD19-positive B-ALL in pediatric and adult ​individuals who are intolerant to or refractory to TKI* therapies    
  • Relapsed or refractory Philadelphia chromosome-positive B-ALL, with or without a TKI †*
ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) IN INFANTS   
  • ​​Induction or consolidation therapy in combination with infant regimens
*TKI options include bosutinib, dasatinib, imatinib, nilotinib, or ponatinib. TKI/mutation contraindications: Bosutinib - T315I, V299L, G250E, or F317L; Dasatinib - T315I/A,​ F317L/V/I/C or V299L; Imatinib too numerous to include; Nilotinib - T315I, Y253H, E255K/V, F359V/C/I or G250E. Ponatinib is a treatment option for individuals with a T315I mutation and/or for individuals for whom no other TKI is indicated.

†If persistent/rising MRD after induction complete response, consider using an alternative/broader TKI for consolidation.

DOSING AND FREQUENCY REQUIREMENTS

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 blinatumomab (Blincyto). 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 blinatumomab (Blincyto) 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 postpayment review and audit procedures for any claims submitted for blinatumomab (Blincyto).

MINIMAL RESIDUAL DISEASE–POSITIVE (MRD+) B-CELL PRECURSOR ACUTE LYMPHOBLASTIC LEUKEMIA (B-ALL)
For MRD+ B-ALL, a treatment course consists of one cycle of blinatumomab (Blincyto) for induction (Cycle 1), followed by up to three additional cycles for consolidation treatment (Cycles two to four). Each cycle consists of 4 weeks of continuous intravenous infusion followed by a 2-week treatment-free interval (total, 42 days). Do not exceed a maximum of 875 mcg, or 25 vials, per month.

      Induction Cycle 1 and Consolidation Cycles 2-4
      • Days 1-28
        • Weight ≥ 45 kg: 28 mcg/day
        • Weight < 45 kg: 15 mcg/m2/day, not to exceed 28 mcg/day
      • Days 29-42: 14-day treatment-free interval
RELAPSED OR REFRACTORY B-CELL PRECURSOR ALL
For relapsed or refractory B-ALL, a treatment course consists of up to two cycles of blinatumomab (Blincyto) for induction (Cycles one to two), followed by three additional cycles for consolidation treatment (Cycles three to five) and up to four additional cycles of continued therapy (Cycles six to nine). Each induction or consolidation therapy cycle consists of 4 weeks of continuous intravenous infusion followed by a 2-week treatment-free interval (total, 42 days). Each continued therapy cycle consists of 4 weeks of continuous intravenous infusion followed by an 8-week treatment-free interval (total, 84 days). Do not exceed a maximum of 875 mcg, or 25 vials, per month.
      Induction Cycle 1, Days 1-7
      • Weight ≥ 45 kg: 9 mcg/day
      • Weight < 45 kg: 5 mcg/m2/day, not to exceed 9 mcg/day

      Induction Cycle 1, Days 8-28
      • Weight ≥ 45 kg: 28 mcg/day
      • Weight < 45 kg: 15 mcg/m2/day, not to exceed 28 mcg/day

      Induction Cycle 1, Days 29-42: 14-day treatment-free interval

      Induction Cycle 2 and Consolidation Cycles 3-5
      • Days 1-28
        • Weight ≥ 45 kg: 28 mcg/day
        • Weight < 45 kg: 15 mcg/m2/day, not to exceed 28 mcg/day
      • Days 29-42: 14-day treatment-free interval

      Consolidation Cycles 6-9
      • Days 1-28
        • Weight ≥ 45 kg: 28 mcg/day
        • Weight < 45 kg: 15 mcg/m2/day, not to exceed 28 mcg/day
      • Days 29-84: 56-day treatment-free interval

INPATIENT ADMISSION

When the medical necessity criteria has been met, the inpatient admission for administration of blinatumomab (Blincyto), as recommended by the FDA, is covered in accordance with the following time-frames*:
  • First Cycle: Days 1-3 of therapy (MRD+ B-Cell Precursor ALL) or Days 1-9 of therapy (Relapsed or Refractory B-Cell Precursor ​ALL)
  • Second Cycle: Days 1-2 of therapy
*Consideration will be given for individuals receiving therapy in subsequent cycle starts and for reinitiation of therapy (e.g., if treatment is interrupted for 4 or more hours). Inpatient hospital stays that are longer than the preceding timeframes must be re-evaluated for medical necessity. Home infusion therapy is an option for subsequent therapy.


NOT MEDICALLY NECESSARY

In accordance with Medicare, utilization of more than 875 units of service (UOS) equivalent to 25 vials of blinatumomab (Blincyto) per month is considered not medically necessary and, therefore, not covered.
  • One UOS equals one microgram (mcg), and, thus, one vial equals 35 UOS.
  • Reconstituted blinatumomab (Blincyto) must be prepared using the combination of vials that result in the least amount of wastage for the dosage amount being administered.
    • Per the manufacturer's 2-day infusion protocol, five vials (or 175 UOS) should be used to reconstitute 6 days of drug.
    • Per the manufacturer's 7-day infusion protocol, six vials (or 210 UOS) should be used to reconstitute 7 days of drug.

EXPERIMENTAL/INVESTIGATIONAL

All other uses of blinatumomab (Blincyto) 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.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the drug. 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 of the drug.

When coverage of blinatumomab (Blincyto) is requested outside of the Dosing and Frequency Requirements 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

This policy is consistent with Medicare’s coverage determination for blinatumomab (Blincyto). The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the applicable Evidence of Coverage, blinatumomab (Blincyto) is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria and Dosing and Frequency Requirements listed in this medical policy are met.

Certain drugs are available only through the member's medical benefit (Part B benefit), depending on how the drug is prescribed, dispensed, or administered. For Medicare Advantage members, blinatumomab (Blincyto) is covered ONLY under a member's medical benefit (Part B benefit).​
US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Blinatumomab (Blincyto) was approved by the FDA on December 3, 2014, for the treatment of Philadelphia chromosome–​negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia (B-ALL). Supplemental approvals for blinatumomab (Blincyto) have since been issued by the FDA.

The safety and effectiveness of blinatumomab (Blincyto) have been established in the pediatric population ​with relapsed or refractory B-ALL. The effectiveness ​has also been established based on extrapolation from adequate and well-controlled studies in adults with MRD-positive B-cell precursor ALL.​

Description

ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

The American Cancer Society estimates that in the year 2022, approximately 6,660 individuals in the United States will be newly diagnosed with acute lymphoblastic leukemia (ALL) (i.e., acute lymphocytic leukemia). Only about one third of all cases will be in adults: the majority of cases occur in children. The 5-year overall survival rate for ALL in children is higher than 90%, but is only 40% to 60% in adults (although these rates vary depending on the subtype of ALL and other prognostic factors).

The goal of therapy is to achieve complete remission, obtain an undetectable minimal residual disease (MRD) result, and to then undergo a hematopoietic stem cell transplant (HSCT). About 70% to 90% of adults will achieve complete remission from ALL after induction therapy; however, approximately half of these individuals will experience relapse due to chemoresistant disease. One indicator of clinical relapse is the MRD result: the lower the MRD measurement, the better the chance of overall survival. It has been reported that up to 80% of individuals who fail to clear MRD experience a clinical relapse despite continued chemotherapy. The role of MRD testing is less understood in adults compared with children due to paucity of data in adults. There is no standard definition of MRD. According to National Comprehensive Cancer Network (NCCN) guidelines for ALL, MRD-positive disease was defined as 0.01% or greater bone marrow mononuclear cells (MNCs); MRD-negative disease was MNCs less than 0.01%. ​

Treatment of ALL is dependent on the particular subtype of the disease. Although most adults are Philadelphia chromosome (Ph)-negative, approximately 20% to 30% of adults with ALL have a genetic mutation referred to as Ph-positive. Treatment of ALL subtypes may consist of chemotherapy (induction, consolidation, and maintenance), tyrosine kinase inhibitors (TKIs) (e.g., dasatinib [Sprycel], imatinib [Gleevec], ponatinib [Iclusig], monoclonal antibodies (e.g., blinatumomab [Blincyto]).

BLINATUMOMAB (BLINCYTO)

A T cell (immune cell) is activated when its receptors bind to the antigens on a cancer cell. The T cell releases cytotoxic components that form pores in the tumor cell's structure and causes cell death. However, cancer cells have found many ways to evade T-cell recognition (e.g., mutation, blocking T-cell signaling). Blinatumomab (Blincyto), a monoclonal antibody, was created to combat this evasion. Blinatumomab (Blincyto) is the first bispecific ​CD19-directed CD3​ T-cell engager (BiTE) immunotherapy product to be approved by the US Food and Drug Administration (FDA). It creates a bridge between the T cell and the cancer cell, by binding to two different proteins at the same time (CD19 located on malignant B cells and CD3 located on T cells); this triggers the activation of the T cells, which ultimately will cause the death of the malignant cells.

Blinatumomab (Blincyto) obtained accelerated approval by the FDA on December 3, 2014, for the treatment of Ph-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia (B-ALL). Subsequent approvals were established for those with Ph-positive relapsed or refractory B-ALL and in those with B-ALL in first or second complete remission with MRD.

CYTOKINE RELEASE SYNDROME
Cytokines are proteins that communicate with cells about the need for immune assistance. Cytokines are secreted by both healthy and cancerous cells. When blinatumomab (Blincyto) infusion is initiated, a transient release (increase) of cytokines occurs in response to the T-cell activation, called cytokine release syndrome (CRS). CRS is common during the initial infusions of monoclonal antibodies and typically subsides with subsequent doses. Symptoms may range from mild in severity to life-threatening or fatal reactions, and include flu-like reactions, hypotension, tachycardia, gastrointestinal disturbances, dyspnea, shock, disseminated intravascular coagulation (DIC), capillary leak syndrome (CLS), and hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). For relapsed or refractory B-cell ALL, it has been reported that the highest risk of CRS occurs during the first 9 days of the first cycle and during the first 2 days of the second cycle of blinatumomab (Blincyto). For MRD-positive B-cell ALL, it has been reported that the highest risk of CRS occurs during the first 3 days of the first cycle and during the first 2 days of the second cycle of blinatumomab (Blincyto). For these reasons, hospitalization is recommended during these days of therapy. Also, per FDA labeling, "For all subsequent cycle starts and reinitiation (e.g., if treatment is interrupted for 4 or more hours), supervision by a healthcare professional or hospitalization is recommended."

PEER-REVIEWED LITERATURE

SUMMARY
The safety and efficacy of blinatumomab (Blincyto) was evaluated in an open-label, multicenter, single-arm, Phase II study of 185 adults with Ph-negative relapsed or refractory B-ALL. Blinatumomab (Blincyto) was administered as a continuous intravenous (IV) infusion. In the first cycle, the initial dose was 9 mcg/day for week 1, then 28 mcg/day for the remaining 3 weeks. In the second and subsequent cycles, 28 mcg/day was administered starting on day 1 of each cycle. The median number of treatment cycles administered was two (range, one to five). A reported 77 of 185 (41.6%) patients achieved complete remission or complete remission with partial hematologic recovery (CR/CRh) within the first two treatment cycles, which was the primary endpoint of the study; the majority of responses (81%, 62 of 77 patients) occurred within the first cycle of treatment. Among those who achieved CR/CRh, 39% (30 of 77 individuals) proceeded to HSCT. There was also a 75% (58 of 77 individuals) achievement of MRD response. The study also reported that 32% of individuals in the study experienced complete remission for approximately 6.7 months after at least 4 weeks of infusion treatment. 

A Phase III, randomized, open-label, multicenter, confirmatory study demonstrating an increase in overall survival was performed by Kantarjian et al. in  2017. Adult participants (N=405) with relapsed or refractory B-ALL were randomly assigned 2:1 to receive blinatumomab (Blincyto) or standard of care chemotherapy. The median number of blinatumomab (Blincyto) cycles received was two (range, one to nine cycles). The median overall survival was statistically significantly longer in the blinatumomab (Blincyto) group (7.7 months) compared with the chemotherapy group (4 months).

Martinelli et al. in 2017 performed an open label, Phase II study of adults with Ph-positive relapsed or refractory B-ALL who had prior treatment with at least one second-generation or later TKI or were intolerant to second-generation or later TKIs and intolerant or refractory to imatinib. The primary endpoint of CR or CRh during the first two cycles of blinatumomab (Blincyto) was obtained by 16 of 45 participants (36%). Additionally, 88% of those who obtained CRh achieved a complete MRD response. The median relapse-free survival and overall survival were 6.7 and 7.1 months, respectively.

The safety and effectiveness of blinatumomab (Blincyto) was studied in the pediatric population (N=70) with relapsed or refractory B-ALL in an open-label, multicenter, single arm trial. The median number of blinatumomab (Blincyto) cycles received was one (range, one to five cycles). Twenty-three of 70 (32.9%) participants achieved CR or CR/CRh within the first two treatment cycles with 17 of 23 (73.9%) occurring within Cycle 1 of treatment.

Gökbuget et al. in 2018 performed an open-label, multicenter, single-arm study of 86 adults with B-ALL who had received at least three chemotherapy blocks of standard ALL therapy, were in first or second hematologic complete remission (CR1 and CR2), and had MRD at a level of 0.1% or greater. Blinatumomab (Blincyto) 15 mcg/m2/day up to a maximum dosage of 28 mcg/day IV was administered for up to four cycles. The primary endpoint was complete MRD response status after one cycle of blinatumomab. Results showed that 73.8% of patients in CR1 and 50% of patients in CR2 obtained complete MRD response. The median hematological relapse-free survival was 35.2 months in patients in CR1 and 12.3 months in patients in CR2.

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. About acute ALL. 01/12/2022. Available at: https://www.cancer.org/cancer/acute-lymphocytic-leukemia.html. Accessed January 6, 2023.​​​

American Cancer Society. Leukemia in children.  Available at: https://www.cancer.org/cancer/leukemia-in-children.html. Accessed January 6, 2023.​​​

American Hospital Formulary Service (AHFS). Drug Information 2023. Blinatumomab. [Lexicomp Online Web site]. 02/22/16. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed January 6, 2023.​​

American Society of Clinical Oncology (ASCO). Leukemia - Acute Lymphocytic - ALL: Overview. 2022. Available at: http://www.cancer.net/cancer-types/leukemia-acute-lymphocytic-all/overview. Accessed January 6, 2023.​​

Blinatumomab (Blincyto) Prescribing Information. Thousand Oaks, CA: Amgen Inc.; 02/2022. Available at: http://www.blincyto.com/. Accessed January 4, 2023.​

Breslin S. Cytokine-release syndrome: overview and nursing implications. Clin J Oncol Nurs. 2007;11(1 Suppl):37-42.

Elsevier’s Clinical Pharmacology Compendium. Blinatumomab. [ClinicalKey Web site]. 03/16/2021. Available at: https://www.clinicalkey.com/pharmacology/ [via subscription only]. Accessed January 6, 2023.​​

Gökbuget N, Dombret H, Bonifacio M, et al. Blinatumomab for minimal residual disease in adults with B-cell precursor acute lymphoblastic leukemia. Blood. 2018;131(14):1522-1531.

Horton TM, McNeer JL. Treatment of acute lymphoblastic leukemia/lymphoma in children and adolescents. [UpToDate Web Site]. 11/29/2022. Available at: http://www.uptodate.com/contents/overview-of-the-treatment-of-acute-lymphoblastic-leukemia-in-children-and-adolescents?source=search_result&search=blincyto&selectedTitle=9~9. Accessed January 6, 2023.​​

Kantarjian H, Stein A, Gökbuget N, et al. Blinatumomab versus chemotherapy for advanced acute lymphoblastic leukemia. N Engl J Med. 2017;376(9):836-847.

Larson RA. Treatment of relapsed or refractory acute lymphoblastic leukemia in adults. [UpToDate Web Site]. 06/03/2022. Available at: http://www.uptodate.com/contents/treatment-of-relapsed-or-refractory-acute-lymphoblastic-leukemia-in-adults?source=search_result&search=blincyto&selectedTitle=4~9. Accessed January 6, 2023.​​

Lexi-Drugs Compendium. Blinatumomab. 01/05/2023. [Lexicomp Online Web site]. Available at: http://online.lexi.com/lco/action/home [via subscription only]. Accessed January 6, 2023.​

Martinelli G, Boissel N, Chevallier P, et al. Complete hematologic and molecular response in adult patients with relapsed/refractory Philadelphia chromosome-positive B-precursor acute lymphoblastic leukemia following treatment with blinatumomab: results from a phase II, single-arm, multicenter study. J Clin Oncol. 2017;35(16):1795-1802.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). ALL. Version 1.2022. 04/04/2022.  [NCCN Website]. Available at: http://www.nccn.org/professionals/physician_gls/pdf/all.pdf [via free subscription]. Accessed January 4, 2023.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Pediatric Acute Lymphoblastic Leukemia. Version 1.2023. 11/09/2022​.  [NCCN Website]. Available at: https://www.nccn.org/professionals/physician_gls/pdf/ped_all.pdf [via free subscription]. Accessed January 4, 2023.​

National Comprehensive Cancer Network (NCCN). NCCN Drugs & Biologics Compendium. Blinatumomab. [NCCN Web site]. 2023. Available at: http://www.nccn.org/professionals/drug_compendium/content/contents.asp [via subscription only]. Accessed January 4, 2023.​​

Noridian Medicare Local Coverage Determination. Local Coverage Article for External Infusion Pumps - Policy Article (A52507). Original 10/01/15. Updated 01/01/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52507​. Accessed January 6, 2023.

Noridian Medicare Local Coverage Determination. Local Coverage Determination (LCD): External Infusion Pumps (L33794). Original: 10/01/2015. Updated 01/01/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33794. Accessed January 6, 2023.​

Seiter K. Acute lymphoblastic leukemia. Updated 07/02/2021. Available at: http://emedicine.medscape.com/article/207631-overview#showall. Accessed January 6, 2023.​

Stock W, Estrov Z. Clinical use of minimal residual disease detection in acute lymphoblastic leukemia. [UpToDate Web Site]. 03/07/2022. Available at: http://www.uptodate.com/contents/clinical-use-of-minimal-residual-disease-detection-in-acute-lymphoblastic-leukemia?source=search_result&search=acute+lymphoblastic+leukemia+adult&selectedTitle=7~150. Accessed January 6, 2023.

Stock W, Estrov Z. Detection of measurable residual disease in acute lymphoblastic leukemia/lymphoblastic lymphoma. [UpToDate Web Site]. 06/16/2022. Available at: https://www.uptodate.com/contents/detection-of-measurable-residual-disease-in-acute-lymphoblastic-leukemia?search=measurable residual disease&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.  Accessed January 6, 2023.​​

Topp MS, Goekbuget N, Stein AS, et al. Confirmatory open-label, single-arm, multicenter phase 2 study of the BiTE antibody blinatumomab in patients (pts) with relapsed/refractory B-precursor acute lymphoblastic leukemia (r/r ALL). 2014 ASCO Annual Meeting - Abstract Number: 7005. J Clin Oncol 2014;32:5s (suppl; abstr 7005).

Topp MS, Gökbuget N, Zugmaier G, et al. Long-term follow-up of hematologic relapse-free survival in a phase 2 study of blinatumomab in patients with MRD in B-lineage ALL. Blood. 2012;120(26):5185-5187.

Topp MS, Kufer P, Gökbuget N, et al. Targeted therapy with the T-cell-engaging antibody blinatumomab of chemotherapy-refractory minimal residual disease in B-lineage acute lymphoblastic leukemia patients results in high response rate and prolonged leukemia-free survival. J Clin Oncol. 2011;29(18):2493-2498.

Truven Health Analytics, Inc. Micromedex® 2.0 Healthcare Series. DrugDex®. Blinatumomab (Blincyto). [Micromedex® Web site]. Updated 01/04/2023. Available at: http://www.micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed January 6, 2023.​

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs @FDA. Blinatumomab (Blincyto) approval letter and prescribing information. [FDA Web site]. 02/2022. Available at:
https://www.accessdata.fda.gov/scripts/cder/daf/. Accessed January 4, 2023.​​​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
ICD10 Medical Codes & Narratives

C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
HCPCS Level II Code Number(s)
J9039 Injection, blinatumomab, 1 microgram
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

​Revisions From ​MA08.058f:
02/27/2023
This version of the policy will become effective 02/27/2023​.​

This policy was updated to communicate the additional Medical Necessity criteria for Acute lymphoblastic leukemia (ALL) in infants, in alignment with National Comprehensive Cancer Network (NCCN) recommendations. 

"RISK EVALUATION AND MITIGATION STRATEGY (REMS)" strategy information was removed from the policy since the FDA released Blincyto of its REMS strategy requirement on 12/05/2022, due to its benefits outweighing any risks.​

Revisions From ​MA08.058e:
06/20/2022This version of the policy will become effective 06/20/2022​​.​

This policy was updated to communicate the changes in the Medical Necessity criteria for Acute lymphoblastic leukemia (ALL) in adults and pediatric individuals with minimal residual disease (MRD+), MRD-, MRD unavailable, or persistent/rising MRD, or relapsed/refractory disease, in alignment with National Comprehensive Cancer Network (NCCN)​ recommendations.

Revisions From MA08.058d:
06/07/2021This version of the policy will become effective 06/07/2021​.​

The policy has undergone a routine review, and the medical necessity criteria have been revised to reflect:
  • The updated US Food and Drug Administration (FDA) terminology by including "CD-19-positive" and "precursor" into the following:
    • CD19-positive B-cell precursor acute lymphoblastic leuke​mia (ALL) ​
  • The updated National Comprehensive Cancer Network (NCCN) criteria for:
    • Ph-negative or Ph-like B-ALL in pediatric individuals who are MRD+ after consolidation therapy
    • Ph-positive B-ALL in pediatric individuals with less than complete response or MRD+ at end of consolidation​​
The following ICD-10 CM code has been added to this policy:
C91.01 Acute lymphoblastic leukemia, in remission​

Revisions From MA08.058c:
​12/02/2020
​This policy has been reissued in accordance with the Company's annual review process. ​
05/22/2019This policy has been reissued in accordance with the Company's annual review process.
10/08/2018This version of the policy will become effective 10/08/2018.

This policy has been updated in consideration of revisions within the US Food and Drug Administration (FDA) labeling, National Comprehensive Cancer Network (NCCN) compendia, and Noridian Medicare for blinatumomab (Blincyto®).

Dosing and Frequency Requirements have been added for all indications.

A position of Not Medically Necessary has been added for doses above 875 units of service (UOS) or 25 vials of blinatumomab (Blincyto®) per month, per Noridian Medicare.

Revisions From MA08.058b:
12/27/2017The policy has undergone a routine review, and the medical necessity criteria have been revised to reflect the updated US Food and Drug Administration (FDA) and National Comprehensive Cancer Network (NCCN) criteria.

Revisions From MA08.058a:
12/21/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on blinatumomab (Blincyto).
01/01/2016This policy has been identified for the HCPCS code update, effective 01/01/2016.

The following HCPCS code has been added to this policy, as Medically Necessary:
J9039 Injection, blinatumomab, 1 microgram

The following HCPCS code has been termed from this policy:
C9449 Injection, blinatumomab, 1 mcg

The following HCPCS codes have been deleted from this policy:
J3590, J7799

Revisions From MA08.058:
07/03/2015This new policy was developed to communicate the Company’s coverage criteria for blinatumomab (Blincyto™).

2/27/2023
2/27/2023
MA08.058
Medical Policy Bulletin
Medicare Advantage
No
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