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Dostarlimab-gxly (Jemperli)
MA08.136c

Policy

When services can be administered in various settings, 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

BREAST CANCER 
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with recurrent unresectable (local or regional) or stage IV (M1) mismatch repair deficient (dMMR) or microsatellite instability-high (MSI-H) breast cancer, as determined by a US Food and Drug Administration (FDA)-approved test, that has progressed on or following prior treatment and has no satisfactory alternative treatment options when one of the following is met:
  • Invasive breast cancer with one of the following histology types:
    • Lobular
    • Mixed
    • Metaplastic
    • Ductal/NST
    • Micropapillary
    • Pure tubular
    • Pure mucinous
    • Pure cribriform
    • Encapsulated or solid papillary carcinoma
    • Other rare forms
    • Adenoid cystic and other salivary carcinomas
    • Secretory carcinoma
    • Rare low-grade forms of metaplastic carcinoma
  • Inflammatory breast cancer (special consideration)
COLON CANCER
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with dMMR/MSI-H only advanced or metastatic colon cancer, as determined by an FDA-approved test, as subsequent therapy if no previous treatment with a checkpoint inhibitor, following previous oxaliplatin- irinotecan- and/or fluoropyrimidine-based therapy

ENDOMETRIAL CANCER
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with dMMR recurrent or advanced endometrial cancer, as determined by an FDA-approved test, when all of the following are met:
  • As second-line treatment for disease that has progressed on or following prior treatment with a platinum-containing regimen when one of the following tumor histology types is present:
    • Serous carcinoma
    • Clear cell carcinoma
    • Carcinosarcoma
    • Endometrioid adenocarcinoma
    • Undifferentiated/dedifferentiated carcinoma
  • The individual has not received more than two lines of therapy for the advanced or recurrent disease
  • The individual has not received prior treatment with programmed death-1 (PD-1)/programmed death-ligand 1 (PD-L1)-blocking antibodies or other immune checkpoint inhibitor therapy
  • The individual does not have autoimmune disease that required systemic therapy with immunosuppressant agents within two years​​
GASTRIC CANCER
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with dMMR or MSI-H gastric tumors, as determined by an FDA-approved test, that have progressed on or following prior treatment and who have no satisfactory alternative treatment options (if no prior tumor progression while on therapy with a checkpoint inhibitor), as palliative therapy for locoregional disease in individuals who are not surgical candidates or have unresectable locally advanced, recurrent, or metastatic disease and Karnofsky performance status (PS) 60 percent or greater or Eastern Cooperative Oncology Group (ECOG) PS 2 or less, as second-line or subsequent therapy.

OCCULT PRIMARY CANCER
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with dMMR/MSI-H occult primary tumors (with adenocarcinoma or carcinoma not otherwise specified histology), as determined by an FDA-approved test, when both of the following are met:
  • One of the following:
    • Symptomatic with an ECOG PS 1 to 2
    • Asymptomatic with an ECOG PS 0 and aggressive disease
  • Any of the following:
    • Axillary involvement in men if clinically indicated
    • Lung nodules or breast marker-negative pleural effusion
    • Resectable liver disease
    • Peritoneal mass or ascites with non-ovarian histology
    • Retroperitoneal mass of non-germ cell histology in selected individuals
    • Unresectable liver disease or disseminated metastases
OVARIAN/FALLOPIAN TUBE/PRIMARY PERITONEAL CANCER
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with recurrent or advanced dMMR or MSI-H ovarian, fallopian tube, or peritoneal persistent or recurrent tumors, as determined by an FDA-approved test, if there is disease progression and no satisfactory alternative treatment options, with the exception for immediate treatment of biochemical relapse, when both of the following are met:
  • One of the following tumor histology types is present:
    • Endometrioid, serous
    • Carcinosarcoma (malignant mixed Mullerian tumors)
    • Clear cell carcinoma
    • Mucinous carcinoma
    • Endometrioid, grade 1
    • Low-grade serous, ovarian borderline epithelial tumors (low malignant potential) with invasive implants
  • One of the following circumstances is present:
    • As immediate treatment for serially rising CA-125 in individuals that previously received chemotherapy
    • For progression on primary, maintenance, or recurrence therapy (platinum-resistant disease)
    • For stable or persistent disease (if not on maintenance therapy) (platinum-resistant disease)
    • For complete remission and relapse <6 months after completing chemotherapy (platinum-resistant disease)
    • For radiographic and/or clinical relapse in individuals with previous complete remission and relapse 6 months or more after completing prior chemotherapy (platinum-sensitive disease)
RECTAL CANCER
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with dMMR/MSI-H only advanced or metastatic rectal cancer, as determined by an FDA-approved test, as subsequent therapy if no previous treatment with a checkpoint inhibitor, following previous oxaliplatin- irinotecan- and/or fluoropyrimidine-based therapy

SMALL BOWEL ADENOCARCINOMA
Dostarlimab-gxly (Jemperli) is considered medically necessary and, therefore, covered for the treatment of adult individuals with dMMR/MSI-H only advanced or metastatic disease, as determined by an FDA-approved test, for either of the following:
  • Small bowel adenocarcinoma as initial or subsequent therapy if no previous treatment with a checkpoint inhibitor and prior oxaliplatin exposure in the adjuvant setting or contraindication to oxaliplatin
  • Advanced ampullary cancer as initial or subsequent therapy if no previous treatment with a checkpoint inhibitor and contraindication to oxaliplatin
EXPERIMENTAL/INVESTIGATIONAL

All other uses of dostarlimab-gxly (Jemperli) 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 service.​

Guidelines

There is no Medicare coverage determination addressing dostarlimab-gxly (Jemperli), therefore, the Company policy is applicable.

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, dostarlimab-gxly (Jemperli) is covered ONLY under a member's medical benefit (Part B benefit).

BENEFIT APPLICATION

Subject to the applicable Evidence of Coverage, dostarlimab-gxly (Jemperli) 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.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

THE KARNOFSKY PERFORMANCE STATUS

The Karnofsky Performance Status (KPS) is a standard way of measuring the ability of individuals with cancer to perform ordinary tasks. Performance scores range from 0 to 100; a higher score indicates that the individual is better able to perform activities. KPS may be used to determine an individual's prognosis, to measure changes in an individual's ability to function, or to decide if an individual can participate in a clinical trial.

The Karnofsky Performance Status Scale
100 percentNormal, no complaints; no signs of disease
90 percentCapable of normal activity; few symptoms or signs of disease
80 percentNormal activity with some difficulty; some symptoms or signs of disease
70 percentCaring for self; not capable of normal activity or work
60 percentRequiring some help; can take care of most personal requirements
50 percentRequires help often; requires frequent medical care
40 percentDisabled; requires special care and help
30 percentSeverely disabled, but no risk of death
20 percentVery ill; requires supportive measures or treatment
10 percentMoribund; rapidly progressive fatal disease processes
0 percentDeath
OncologyPro. Performance scales: Karnofsky & ECOG scores. [OncologyPro Web site]. Available at: https://oncologypro.esmo.org/oncology-in-practice/practice-tools/performance-scales.

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
GradeECOG
0Fully active, able to carry on all pre-disease performance without restriction
1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (eg, light house work, office work)
2Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50 percent of waking hours
3Capable of only limited self care, confined to bed or chair more than 50 percent of waking hours
4Completely disabled. Cannot carry on any self care: Totally confined to bed or chair
5Dead
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

Dostarlimab-gxly (Jemperli) was approved by the FDA on April 22, 2021, as an accelerated approval based on tumor response rate and durability of response for the treatment of individuals with mismatch repair deficient (dMMR) recurrent or advanced endometrial cancer that has progressed on or following prior treatment with a platinum-containing regimen. Supplemental approvals for dostarlimab-gxly (Jemperli) have since been issued by the FDA.

Refer to the dostarlimab-gxly (Jemperli) prescribing information for further information on FDA-approved tests for determining mismatch repair deficiency. 

PEDIATRIC USE
Dostarlimab-gxly (Jemperli) is not indicated for use in pediatric individuals less than 18 years of age.​

Description

Approximately 15,000 individuals in the United States are diagnosed with either advanced or recurrent endometrial cancer (EC) annually. Some of the risk factors for EC are hormone therapy, obesity, metabolic syndrome, diabetes, family history, and certain genetic syndromes (e.g. Lynch syndrome). A common sign of EC is irregular vaginal bleeding, which usually occurs early in the cancer process, leading to a diagnosis of EC while the cancer is in an early stage. When identified in an early stage, EC can be successfully treated with either surgery alone, or in combination with radiotherapy and/or chemotherapy, which is often platinum based. If identified in later stages, or if it is recurrent or refractory to treatment, the prognosis for EC is poor. The current treatment options are limited.

There are genes within the cells of the body that correct mistakes made when the deoxyribonucleic acid (DNA) is copied. The process is called mismatch repair. Mismatch repair deficiency (dMMR) can result in errors in short, repetitive DNA sequences called microsatellites, which are genetic mutations. If a tumor has a high number of these mutations, it is classified as expressing microsatellite instability (MSI). EC tumors with dMMR and microsatellite instability-high (MSI-H) expression are difficult to treat. Based on clinical studies involving other drugs, tumors with dMMR and MSI-H respond well to anti-programmed death 1 (PD-1)-based immune checkpoint inhibitor immunotherapy.

Dostarlimab-gxly (Jemperli) is a programmed death-1 (PD-1)-blocking immunoglobulin G4 (IgG4) humanized monoclonal antibody. Binding of the PD-1 ligands, PD-L1 and PD-L2, to the PD-1 receptor found on T cells, part of the body's immune response against foreign material, inhibits T-cell proliferation and cytokine production. Upregulation of PD-1 ligands occurs in some tumors and signaling through this pathway can contribute to inhibition of active T-cell immune surveillance of tumors leading to tumor growth. Dostarlimab-gxly (Jemperli) binds to the PD-1 receptor on the T cells and blocks its interaction with PD-L1 and PD-L2 which allows the anti-tumor immune response to occur.

Dostarlimab-gxly (Jemperli) was approved by the US Food and Drug Administration (FDA) on April 22, 2021 for the treatment of individuals with mismatch repair deficient (dMMR) recurrent or advanced endometrial cancer that has progressed on or following prior treatment with a platinum-containing regimen.​

PEER-REVIEWED LITERATURE

SUMMARY
Endometrial Cancer

Dostarlimab-gxly (Jemperli) was evaluated in the GARNET study (NCT02715284), which is an ongoing multicenter, multicohort, open-label study conducted in individuals with advanced solid tumors. The efficacy population consisted of a cohort of 71 individuals with mismatch repair deficient (dMMR) recurrent or advanced EC who had progressed on or after treatment with a platinum-containing regimen. The major efficacy outcome measures were objective response rate (ORR) and duration of response (DOR) as assessed by blinded independent central review (BICR) according to the Response Evaluation Criteria in Solid Tumors (RECIST) v 1.1.

At the time of study entry 66 percent of the individuals with dMMR EC had stage IV disease. All individuals with dMMR EC had received prior anticancer treatment, with 90 percent having received prior anticancer surgery and 79 percent having received prior anticancer radiotherapy. Approximately 40 percent had two lines or more of prior anticancer treatment, 11 percent had received three regimens, and four percent had received four or more prior regimens. The ORR was 42.3 percent with 12.7 percent achieving complete response and 29.6 percent achieving a partial response. The DOR was not reached, but 93.3 percent of individuals had a duration of response greater than or equal to six months. A couple limitations of the study were the lack of a comparator group and the small cohort size. Additional studies are currently enrolling participants.

Solid Tumors

Dostarlimab-gxly (Jemperli) was evaluated in the GARNET study (NCT02715284), which is an ongoing multicenter, multicohort, open-label study conducted in individuals with advanced solid tumors. The efficacy population consisted of a cohort of 209 individuals with dMMR recurrent or advanced solid tumors who had progressed following systemic therapy and had no satisfactory alternative treatment options. Individuals with dMMR colorectal cancer must have progressed after or been intolerant to a fluoropyrimidine, oxaliplatin, and irinotecan. The major efficacy outcome measures were ORR and DOR as assessed by blinded independent central review (BICR) according to RECIST v 1.1.

At the time of study entry 97.2 percent of individuals with non-endometrial dMMR solid tumors had stage IV disease. Approximately 43 percent of individuals had received one prior line of systemic anticancer treatment, 36 percent had received two prior lines, and 21 percent had received three or more prior lines. The ORR was 41.6 percent with 9.1 percent achieving complete response and 32.5 percent achieving a partial response. The median DOR was 34.7 months with 95.4 percent of individuals surviving six months or more.​

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 Hospital Formulary Service (AHFS). Dostarlimab-gxly (Jemperli). AHFS Drug Information 2021. [LexiComp Web site]. 06/11/2021. Available at: https://online.lexi.com/lco/action/home# [via subscription only]. Accessed December 15, 2021.

ClinicalTrials.gov. Study of TSR-042, an Anti-programmed Cell Death-1 Receptor (PD-1) Monoclonal Antibody, in participants with advanced solid tumors (GARNET). ClinicalTrials.gov identifier: NCT02715284. First Posted: 03/22/2016; Last Update Posted: 11/02/2021. Available at: https://clinicaltrials.gov/ct2/show/NCT02715284?term=NCT02715284&draw=2&rank=1. Accessed December 15, 2021.

Elsevier’s Clinical Pharmacology Compendium. Dostarlimab-gxly (Jemperli). [Clinicalkey Web site]. 08/24/2021. Available at: https://www.clinicalkey.com/phamacology/ [via subscription only]. Accessed December 15, 2021.

IBM Micromedex® DRUGDEX® (electronic version). Dostarlimab-gxly (Jemperli). [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. Dostarlimab-gxly (Jemperli). [Lexicomp Online Web site]. 11/15/2021. Available at: https://online.lexi.com/lso/action/home [via subscription only]. Accessed December 15, 2021.

National Cancer Institute. Endometrial cancer treatment. 04/09/2021. Available at: https://www.cancer.gov/types/uterine/hp/endometrial-treatment-pdq#_73. Accessed December 15, 2021.

National Cancer Institute (NCI). NCI Dictionary of Cancer Terms. Microsatellite instability-high cancer. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/microsatellite-instability-high-cancer. Accessed December 15, 2021.

National Cancer Institute (NCI). NCI Dictionary of Cancer Terms. Mismatch repair deficiency. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/mismatch-repair-deficiency. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Breast Cancer. V1.2022. [NCCN Web site]. 11/24/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Colon Cancer. V3.2021. [NCCN Web site]. 09/10/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Gastric Cancer. V5.2021. [NCCN Web site]. 10/06/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/gastric.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Occult Primary (Cancer of Unknown Primary [CUP]). V1.2022. [NCCN Web site]. 09/02/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/occult.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. V3.2021. [NCCN Web site]. 09/09/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Rectal Cancer. V2.2021. [NCCN Web site]. 09/10/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Small Bowel Adenocarcinoma. V1.2022. [NCCN Web site]. 09/10/2021. Available from: https://www.nccn.org/professionals/physician_gls/pdf/small_bowel.pdf. [via subscription only]. Accessed December 15, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology® - Uterine Neoplasms. V1.2022. [NCCN Web site]. 11/04/2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/uterine/pdf [via subscription only]​. Accessed December 15, 2021.

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

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.

Oaknin A, Tinker AV, Gilbert L, et al. Clinical activity and safety of the anti-PD-1 monoclonal antibody dostarlimab for patients with recurrent or advanced dMMR endometrial cancer. Future Oncol. 2021;17(29):3781-3785.

Oaknin A, Tinker AV, Gilbert L, et al. Clinical activity and safety of the anti-programmed death 1 monoclonal antibody dostarlimab for patients with recurrent or advanced mismatch repair-deficient endometrial cancer: a nonrandomized phase 1 clinical trial. JAMA Oncol. 2020;6(11):1-7.

OncologyPro. Performance scales: Karnofsky & ECOG scores. [OncologyPro Web site]. Available at: https://oncologypro.esmo.org/oncology-in-practice/practice-tools/performance-scales. Accessed December 15, 2021.

Overman MJ, Morse M. Tissue-agnostic cancer therapy: DNA mismatch repair deficiency, tumor mutational burden, and response to immune checkpoint blockade in solid tumors. [UpToDate Web Site]. Updated 01/03/2022. Available at: http://www.uptodate.com/home [via subscription only]. Accessed January 12, 2022.​

Patnaik A, Weiss GJ, Rasco DW, et al. Safety, antitumor activity, and pharmacokinetics of dostarlimab, an anti-PD-1, in patients with advanced solid tumors: a dose-escalation phase 1 trial. Cancer Chemother Pharmacol. 2022;89(1):93-103.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Dostarlimab-gxly (Jemperli) prescribing information and approval letter. [FDA Web site]. 08/17/2021. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm. Accessed December 15, 2021.

US Food and Drug Administration (FDA). List of cleared or approved companion diagnostic devices (in vitro and imaging tools). 12/01/2021. Available at: https://www.fda.gov/medical-devices/in-vitro-diagnostics/list-cleared-or-approved-companion-diagnostic-devices-in-vitro-and-imaging-tools. 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)
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C16.9 Malignant neoplasm of stomach, unspecified
C17.0 Malignant neoplasm of duodenum
C17.1 Malignant neoplasm of jejunum
C17.2 Malignant neoplasm of ileum
C17.3 Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C17.9 Malignant neoplasm of small intestine, unspecified
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
C21.0  Malignant neoplasm of anus, unspecified
C21.1   Malignant neoplasm of anal canal
C21.2  Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C24.1 Malignant neoplasm of ampulla of Vater
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
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
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
C56.3 Malignant neoplasm of bilateral ovaries
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
C57.7 Malignant neoplasm of other specified female genital organs
C57.8 Malignant neoplasm of overlapping sites of female genital organs
C57.9 Malignant neoplasm of female genital organ, unspecified
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
C80.0 Disseminated malignant neoplasm, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
D07.0 Carcinoma in situ of endometrium
D37.1 Neoplasm of uncertain behavior of stomach​



HCPCS Level II Code Number(s)
J9272 Injection, dostarlimab-gx ly, 10 mg​

Revenue Code Number(s)
N/A




Coding and Billing Requirements


Policy History

3/28/2022
3/28/2022
MA08.136
Medical Policy Bulletin
Medicare Advantage
No