09/28/2020
| This version of the policy will become effective 09/28/2020. New policy number MA08.127 supersedes MA08.010j for atezolizumab (Tecentriq®).
The following criteria have been revised in this policy for non-small cell lung cancer, and urotherlial cancer - In accordance with National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium® 2020 and/or FDA labeling through 07/30/2020
The following criteria have been added to this policy for triple negative breast cancer, hepatocellular cancer, small cell lung cancer and melanoma
- In accordance with FDA labeling through 07/30/2020 and/or NCCN Drugs and Biologics Compendium® 2020.
The following ICD-10 CM codes have been added to this policy:
C22.0, C22.8, C22.9, C43.0, C43.10, C43.111, C43.112, C43.121, C43.122, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9, C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322, C50.329, C50.411, C50.412, C50.419, C50.421, C50.422, C50.429 C50.511 C50.512 C50.519 C50.521, C50.522, C50.529, C50.611, C50.612, C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819, C50.821, C50.822, C50.829, C50.911, C50.912, C50.919, C50.921, C50.922, C50.929 |