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Bortezomib (Bortezomib for Injection, Velcade®)
MA08.037h

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.

INDEX OF MEDICALLY NECESSARY INDICATIONS
 
This policy addresses numerous medically necessary indications for the use of Bortezomib (Bortezomib for Injection, Velcade) listed in order of appearance within the Policy section. Please see below for the specific medical necessity criteria. (NOTE: Experimental/Investigational section below must also be reviewed).

  • Adult acute lymphoblastic leukemia​
  • ​Adult T-cell leukemia/lymphoma​
  • Castleman's disease
  • ​Kaposi sarcoma​
  • Mantle cell lymphoma
  • Multiple myeloma
  • Pediatric acute lymphoblastic leukemia
  • Pediatric Hodgkin lymphoma
  • Systemic light-chain amyloidosis
  • Waldenstrom's macroglobulinemia/lymphoplasmacytic lymphoma​
MEDICALLY NECESSARY

ADULT ACUTE LYMPHOBLASTIC LEUKEMIA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for adult acute lymphoblastic leukemia used in combination with chemotherapy for relapsed/refractory Philadelphia chromosome negative T-ALL 
ADULT T-CELL LEUKEMIA/LYMPHOMA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for adult T-cell leukemia/lymphoma as second-line therapy or subsequent therapy as a single agent for nonresponders to first-line therapy for acute or lymphoma subtypes ​

CASTLEMAN'S DISEASE (CD)
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for Castleman’s disease as subsequent therapy with or without rituximab for multicentric CD that has progressed following treatment of relapsed/refractory or progressive disease 

KAPOSI SARCOMA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for Kaposi sarcoma as subsequent systemic treatment given alone (no HIV) or with antiretroviral therapy (ART) for individuals with HIV (people with HIV [PWH}) for relapsed/refractory advanced cutaneous, oral, visceral, or nodal disease that has progressed on or not responded to first-line systemic therapy, and ​progressed on the alternate first-line systemic therapy

MANTLE CELL LYMPHOMA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for mantle cell lymphoma with one of the following: 
  • Treatment of individuals with untreated or relapsed mantle cell lymphoma (bortezomib [Velcade])
  • Treatment of individuals with relapsed mantle cell lymphoma who have received at least one prior therapy (bortezomib [Bortezomib for Injection])
  • Less aggressive induction therapy for stage I-II disease as initial therapy (an National Comprehensive Cancer Network [NCCN]-preferred regimen), or as additional therapy for partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease or symptomatic indolent stage II bulky, III, or IV TP53 mutation positive disease in ​individuals who are not candidates for high-dose therapy/autologous stem cell rescue as a component of VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) ​regimen​ 
  • Second-line and subsequent therapy for stage I-II disease, aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV disease in individuals who have stable disease or partial response* with substantial disease after ​induction therapy, or for relapsed or progressive disease following prior treatment with chemoimmunotherapy, in one of the following regimens:
    • As a single agent ​
    • In combination with rituximab
*  Individuals who have achieved a near complete response can proceed to high-dose therapy/autologous stem cell rescue. Individuals who have achieved minimal partial response with substantial disease should be treated as having stable, refractory disease. Individuals who have achieved a very good partial response may be treated with additional therapy to achieve complete response with the goal of proceeding to high-dose therapy/autologous stem cell rescue.

MULTIPLE MYELOMA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for multiple myeloma with one of the following: 

Treatment for newly diagnosed or previously untreated multiple myeloma:

 When the candidacy for autologous stem cell transplantation is not known/not specified:
  • As a single agent or
  • In combination with one of the following:
    • Dexamethasone 
    • Dexamethasone and lenalidomide (NCCN preferred) 
    • Dexamethasone and cyclophosphamide (NCCN preferred as initial treatment in those with acute renal insufficiency or those who have no access to combination with dexamethasone and lenalidomide)
When the individual is known to be a candidate for autologous stem cell transplantation:
  • In combination with one of the following:
    • Dexamethasone​
    • Dexamethasone and doxorubicin 
    • Dexamethasone and thalidomide 
    • Dexamethasone and cyclophosphamide
    • Dexamethasone, daratumumab, and cyclophosphamide 
    • Dexamethasone, daratumumab, and lenalidomide 
    • Dexamethasone, daratumumab, and thalidomide 
  • Autologous stem cell transplantation induction with a bortezomib-containing regimen (e.g., bortezomib, dexamethasone, and lenalidomide; or bortezomib and dexamethasone; or bortezomib, dexamethasone, and thalidomide; or bortezomib, dexamethasone, and doxorubicin [or liposomal doxorubicin]; or bortezomib, dexamethasone, and cyclophosphamide) 
  • In VTD-PACE (bortezomib, thalidomide, dexamethasone, cisplatin, doxorubicin, cyclophosphamide and etoposide) regimen (generally reserved for the treatment of aggressive multiple myeloma)
  • Dexamethasone for the management of POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome as induction therapy
  • As a single agent as maintenance therapy for symptomatic multiple myeloma after response to primary myeloma therapy or for response or stable disease after HSCT 
  • Lenalidomide as maintenance therapy for symptomatic multiple myeloma after response to primary myeloma therapy or for response or stable disease after HSCT (dual maintenance recommended for high-risk disease) 
  • Dexamethasone and lenalidomide as maintenance therapy for symptomatic multiple myeloma after response to primary myeloma therapy or for response or stable disease after HSCT (dual maintenance recommended for high-risk disease) ​
When the individual is known to not be a candidate for autologous stem cell transplantation:
  • In combination with one of the following:
    • Dexamethasone 
    • Prednisone and melphalan 
    • Prednisone, melphalan, and daratumumab 
    • Prednisone, melphalan, daratumumab, hyaluronidase 
    • Prednisone, melphalan, and thalidomide followed by maintenance regimen combination with thalidomide 
    • Dexamethasone, cyclophosphamide, and daratumumab 
    • Dexamethasone for the management of POEMS syndrome
    • As part of VRd-lite (bortezomib, lenalidomide, and dexamethasone) regimen (useful in certain circumstances, for frail individuals) 
Treatment for relapsed multiple myeloma:

When the candidacy for autologous stem cell transplantation is not known/not specified:
  • As a single agent after response to primary therapy after six months following primary induction therapy with the same regimen or as maintenance therapy or
  • In combination with one of the following:
    • Dexamethasone 
    • Doxorubicin in individuals who have not previously received bortezomib or have received at least one prior therapy ​
    • Dexamethasone and daratumumab (NCCN preferred) 
    • Dexamethasone and liposomal doxorubicin 
    • Dexamethasone and elotuzumab 
    • Dexamethasone and selinexor (once weekly) 
    • Dexamethasone and bendamustine 
    • Lenalidomide after response to primary therapy as maintenance therapy
    • Dexamethasone, after six months following primary induction therapy with or without the same regimen 
    • Dexamethasone and lenalidomide, after six months following primary induction therapy with the same regimen (NCCN preferred) 
    • Dexamethasone and panobinostat for individuals who have received at least two prior regimens, including bortezomib and an immunomodulatory agent 
    • Dexamethasone and cyclophosphamide, after six months following primary induction therapy with the same regimen (NCCN-preferred as initial treatment in those with acute renal insufficiency or those who have no access to bortezomib/lenalidomide/dexamethasone)
    • Dexamethasone and pomalidomide for individuals who have received at least two prior therapies, including an immunomodulatory agent and a proteasome inhibitor and who have demonstrated disease progression on or within 60 days of completion of the last therapy (NCCN preferred)
    • In VTD-PACE regimen (generally reserved for the treatment of aggressive multiple myeloma) 
When the individual is known to be a candidate for autologous stem cell transplantation:
  • In combination with one of the following:
    • Dexamethasone, cyclophosphamide and daratumumab, after six months following primary induction therapy with the same regimen 
    • In VTD-PACE regimen, after six months following primary induction therapy with the same regimen (generally reserved for the treatment of aggressive multiple myeloma)
    • Lenalidomide for response or stable disease following autologous stem cell transplantation as maintenance therapy
When the individual is known to not be a candidate for autologous stem cell transplantation:
In combination with one of the following:
  • Dexamethasone, cyclophosphamide and daratumumab, after six months following primary induction therapy with the same regimen
  • Dexamethasone, after six months following primary induction therapy with the same regimen 
PEDIATRIC ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for pediatric acute lymphoblastic leukemia with one of the following:
  • As a single agent for the treatment for relapsed/refractory Philadelphia chromosome (Ph)-negative B-cell (B)-ALL, or in combination with dasatinib or imatinib for relapsed/refractory Ph-positive B-ALL as a component of COG AALL07P1 regimen (bortezomib, vincristine, doxorubicin, pegaspargase, and prednisone or dexamethasone)
  • Treatment for relapsed/refractory T-cell (T)-ALL as a component of a bortezomib-containing regimen (e.g., bortezomib, vincristine, doxorubicin, pegaspargase, and prednisone or dexamethasone)
PEDIATRIC HODGKIN LYMPHOMA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for pediatric Hodgkin lymphoma as subsequent therapy in combination with ifosfamide and vinorelbine for relapsed or refractory disease 

SYSTEMIC LIGHT-CHAIN AMYLOIDOSIS
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for systemic light-chain amyloidosis with one of the following:
  • Treatment for newly diagnosed disease or for relapsed/refractory disease as a repeat of initial therapy if relapse-free for several years, in one of the following regimens​:
    • As a single agent ​
    • In combination with:
      • Dexamethasone ​​
      • Dexamethasone and melphalan 
      • Dexamethasone and lenalidomide 
      • Dexamethasone and cyclophosphamide (NCCN preferred) 
      • An alkylating agent and a steroid as first-line treatment 
      • Dexamethasone, daratumumab, hyaluronidase, cyclophosphamide (NCCN preferred) 
  • Treatment for relapsed/refractory disease, in one of the following regimens:
    • ​As a single agent ​
    • In combination with:
      • Dexamethasone ​
      • Dexamethasone and melphalan
​​​WALDENSTROM'S MACROGLOBULINEMIA/LYMPHOPLASMACYTIC LYMPHOMA
Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for Waldenstrom’s macroglobulinemia or lymphoplasmacytic lymphoma as primary therapy, or consider for relapse if previously used as primary therapy that was well tolerated and elicited a prolonged response, or as alternative therapy for previously treated disease that does not respond to primary therapy, or for progressive or relapsed disease, in one of the following regimens:​
  • As a single agent
  • In combination with rituximab
  • In combination with dexamethasone
  • In combination with dexamethasone and rituximab (NCCN preferred)​​
EXPERIMENTAL/INVESTIGATIONAL

All other uses of bortezomib (Bortezomib for Injection, Velcade) 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 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

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable.

Bortezomib (Bortezomib for Injection, Velcade) is available through either the member's medical benefit (Part B benefit) or pharmacy benefit (Part D benefit), depending on how the drug is prescribed, dispensed, or administered. This medical policy only addresses instances when bortezomib (Bortezomib for Injection, Velcade) is covered under a member's medical benefit (Part B benefit). It does not address instances when bortezomib (Bortezomib for Injection, Velcade) is covered under a member’s pharmacy benefit (Part D benefit).

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, bortezomib (Bortezomib for Injection, Velcade) is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Bortezomib (Velcade) was approved by the FDA on May 13, 2003 for ​intravenous use in the treatment of individuals with multiple myeloma. On December 8, 2006, bortezomib (Velcade) was approved by the FDA for the use in the treatment of individuals with mantle cell lymphoma. On January 23, 2012, bortezomib (Velcade) was approved by the FDA for subcutaneous use.​ Supplemental approvals for bortezomib (Velcade) have since been issued by the FDA.

Bortezomib (Bortezomib for Injection) was approved by the FDA on November 6, 2017 for intravenous use in the treatment of individuals with multiple myeloma and for use in the treatment of individuals with mantle cell lymphoma who have received at least one prior therapy.

PEDIATRIC USE
The safety and effectiveness of bortezomib (Velcade) and bortezomib (Bortezomib for Injection) in children have not been established although off-label uses have been recognized by drug compendia​.

Description

Bortezomib (Bortezomib for Injection, Velcade) is a proteasome inhibitor, which is used for targeted antineoplastic therapy. The proteasome is an enzyme complex that is found in all biological cells. It is involved in degrading proteins that control the cell cycle and in cellular processes that maintain cell homeostasis. By blocking the proteasome, bortezomib (Bortezomib for Injection, Velcade) disrupts numerous biologic pathways, including those related to the growth and survival of cancer cells. Bortezomib (Bortezomib for Injection, Velcade) has demonstrated the ability to delay tumor growth in vivo in several tumor models, including multiple myeloma.

On May 13, 2003, bortezomib (Velcade), administered intravenously, was approved by the US Food and Drug Administration (FDA) as an orphan drug (a drug used to treat, prevent, or diagnose a rare disease) under the accelerated approval program for use in the treatment of individuals with multiple myeloma who had received at least two prior therapies. On March 25, 2005, the FDA decreased the requirement to only one prior therapy. On May 17, 2007, the FDA approved bortezomib (Velcade) plus doxorubicin HCl liposome injection (Doxil®) combination for the treatment of individuals with multiple myeloma who had previously not taken bortezomib (Velcade) and who have received at least one prior therapy​. On June 20, 2008, the FDA granted supplemental approval for bortezomib (Velcade) that removed the prior therapy requirement for individuals with multiple myeloma.

On December 8, 2006, the FDA approved the use of bortezomib (Velcade) in the treatment of individuals with mantle cell lymphoma (a form of non-Hodgkin's lymphoma affecting the B-lymphocytes) who have received at least one prior therapy. On October 8, 2014, the FDA removed the at least one prior therapy requirement for individuals with mantle cell lymphoma.

On January 23, 2012, based on results from a randomized Phase 3 non-inferiority trial, the FDA granted a supplemental approval for bortezomib (Velcade) for subcutaneous route of administration for treatment of individuals with multiple myeloma and for treatment of individuals with mantle cell lymphoma who have received at least one prior therapy. In general, the overall response rate and complete response rates of bortezomib (Velcade) administered subcutaneously or intravenously achieved similar efficacy regardless of how bortezomib (Velcade) was administered. However, differences were observed in the incidence of peripheral neuropathy experienced in the trial. In the subcutaneous arm of the study, six percent of individuals experienced Grade 3 (i.e., severe symptoms; limiting self-care activities of daily living) or higher peripheral neuropathy, compared to 16 percent in the intravenous arm of the study.

On November 6, 2017, bortezomib (Bortezomib for Injection) was approved by the FDA for the intravenous use in the treatment of individuals with multiple myeloma and in the treatment of individuals with mantle cell lymphoma who have received at least one prior therapy. Bortezomib (Bortezomib for Injection) was approved through the 505(b)(2) NDA pathway process. This product is formulated with boric acid or glycine, while bortezomib (Velcade) contains mannitol.

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 Hospital Formulary Service (AHFS). Bortezomib (Velcade®). AHFS Drug Information 2021. [LexiComp Web site]. 02/26/2021. Available at: https://online.lexi.com/lco/action/home# [via subscription only]. Accessed December 15, 2021.

Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and Non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32(27):3059-3067.​

Elsevier's Clinical Pharmacology Compendium. Bortezomib (Velcade®). [Clinical Key Web site]. 10/27/2021. Available at: https://www.clinicalkey.com/#!/ [via subscription only]. Accessed December 15, 2021.

Horton TM, Whitlock JA, Lu X, et al. Bortezomib reinduction chemotherapy in high-risk ALL in first relapse: a report from the Children’s Oncology Group. Br J Haematol. 2019;186(2):274-285.

IBM Micromedex® DRUGDEX® (electronic version). Bortezomib (Velcade®). [Micromedex Web site]. IBM Watson Health, Greenwood Village, Colorado, USA. 11/06/2021. Available at: https://www.micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed December 15, 2021.

Lexi-Drugs Compendium. Bortezomib (Velcade®). [LexiComp Web site]. 11/22/2021. Available at: https://online.lexi.com/lco/action/home [via subscription only]. Accessed December 15, 2021.

Moreau P, Pylypenko H, Grosicki S, et. al. Subcutaneous versus intravenous administration of bortezomib in patients with relapsed multiple myeloma: a randomized, phase 3, non-inferiority study. Lancet Oncol. 2011;12:431-440.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Acute Lymphoblastic Leukemia V2.2021. [NCCN Web site]. 07/19/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/all.pdf [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - B-cell Lymphomas V5.2021. [NCCN Web site]. 09/22/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdf [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Kaposi Sarcoma V2.2021. [NCCN Web site]. 06/07/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/kaposi.pdf [via subscription only]. Accessed December 15, 2021

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Multiple Myeloma V4.2022. [NCCN Web site]. 12/14/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Pediatric Acute Lymphoblastic Leukemia ​V1.2022. [NCCN Web site]. 10/01/2021. Available at: ​https://www.nccn.org/professionals/physician_gls/pdf/ped_all.pdf ​[via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Pediatric Hodgkin Lymphoma ​​V3.2021. [NCCN Web site]. 03/18/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/ped_hodgkin.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Systemic Light Chain Amyloidosis V1.2022. [NCCN Web site]. 06/29/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/amyloidosis.pdf [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - T-Cell Lymphomas V1.2021. [NCCN Web site]. 10/05/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/t-cell.pdf [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma. V2.2022. [NCCN Web site]. 12/07/2021. Available at: http://www.nccn.org/professionals/physician_gls/pdf/waldenstroms.pdf [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Drugs & Biologics Compendium®. [NCCN Web site]. Bortezomib (Velcade®). Available at: ​http://www.nccn.org/professionals/drug_compendium/content/contents.asp. [via subscription only]. Accessed December 15, 2021.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Bortezomib (Velcade®). Supplemental approval letter. [FDA Web site]. 05/13/2003. Available at: ​http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2003/21602ltr.pdf. Accessed December 15, 2021.

​US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Bortezomib (Bortezomib for Injection). Prescribing information and approval letter. [FDA Web site]. 09/20/2021. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm. Accessed December 15, 2021.

​US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Bortezomib (Velcade®). Prescribing information and approval letter. [FDA Web site]. 11/04/2021. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm. Accessed December 15, 2021.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Daratumumab (Darzalex®). Prescribing information and approval letter. [FDA Web site]. 07/09/2021. Available at:  https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm​. Accessed December 15, 2021.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Doxorubicin (Doxil®). Prescribing information and approval letter. [FDA Web site].​ 08/12/2019. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm​. Accessed December 15, 2021.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Panobinostat (Farydak®). Prescribing information and approval letter. [FDA Web site]. 02/23/2015. Available at:  https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm​. Accessed December 15, 2021.​

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)

J9041 Injection, bortezomib (velcade), 0.1 mg

J9044 Injection, bortezomib, not otherwise specified, 0.1 mg​​


Revenue Code Number(s)
N/A






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

4/11/2022
4/11/2022
MA08.037
Medical Policy Bulletin
Medicare Advantage
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No