Medicare Advantage

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

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).

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

Bortezomib (Bortezomib for Injection) intravenous and bortezomib (Velcade) intravenous or subcutaneous injection are considered medically necessary and, therefore, covered for any of the following indications:

AIDS-RELATED KAPOSI SARCOMA
Subsequent systemic treatment given with antiretroviral therapy (ART) for relapsed/refractory advanced cutaneous, oral, visceral, or nodal disease that has progressed on or not responded to first-line systemic treatment and ​progressed on the alternate first-line systemic treatment

CASTLEMAN'S DISEASE (CD)
Subsequent therapy with or without rituximab for multicentric CD that has progressed following treatment of relapsed/refractory or progressive disease

MANTLE CELL LYMPHOMA
  • 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]) 
  • Induction therapy for stage I-II disease as initial therapy (an National Comprehensive Cancer Network [NCCN-preferred] regimen), or for partial response, progression, or relapse after 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 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 an extended response duration to prior chemoimmunotherapy (> expected median progression free survival)
    • as a single agent (NCCN-preferred regimen) 
    • in combination with rituximab (NCCN-preferred regimen)
  • ​Second-line therapy for stage I-II disease, aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV disease to achieve a complete response after very good partial response to induction therapy with the goal of proceeding to high-dose therapy/autologous stem cell rescue:
    • as a single agent (NCCN-preferred regimen) 
    • in combination with rituximab (NCCN-preferred regimen) 
    • as a component of VR-CAP regimen (if not previously given; NCCN-preferred regimen)

MULTIPLE MYELOMA

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 any 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 any of the following:
    • dexamethasone and doxorubicin 
    • dexamethasone and thalidomide 
    • 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 


When the individual is known to not be a candidate for autologous stem cell transplantation:

  • In combination with any of the following:
    • dexamethasone 
    • prednisone and melphalan 
    • prednisone, melphalan, and daratumumab 
    • prednisone, melphalan, and thalidomide followed by maintenance regimen combination with thalidomide 
    • dexamethasone, cyclophosphamide, and daratumumab 
  • dexamethasone for the management of POEMS syndrome as induction therapy


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 any of the following:
    • dexamethasone and daratumumab (NCCN preferred) 
    • dexamethasone and liposomal doxorubicin 
    • dexamethasone and elotuzumab 
    • dexamethasone and selinexor 
    • 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)


When the individual is known to be a candidate for autologous stem cell transplantation:

  • As a single agent for response or stable disease following autologous stem cell transplantation as maintenance therapy or
  • In combination with any 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 any 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)
  • 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
Subsequent therapy in combination with ifosfamide and vinorelbine for relapsed or refractory disease

SYSTEMIC LIGHT-CHAIN AMYLOIDOSIS ​
Treatment for newly diagnosed disease or for relapsed/refractory disease as a repeat of initial therapy if relapse-free for several years:
  • As a single agent 
  • In combination with: 
    • dexamethasone 
    • dexamethasone and melphalan ​
    • dexamethasone and lenalidomide ​
    • dexamethasone and cyclophosphamide (NCCN preferred) ​
​Treatment for relapsed/refractory disease: 

  • As a single agent ​
  • ​In combination with:
    • dexamethasone​ ​
    • dexamethasone and melphalan​

T-CELL LEUKEMIA/LYMPHOMA, ADULT
Second-line therapy or subsequent therapy as a single agent for nonresponders to first-line therapy for acute or lymphoma subtypes

WALDENSTROM'S MACROGLOBULINEMIA/LYMPHOPLASMACYTIC LYMPHOMA

Used as primary therapy, or 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:

  • As a single agent or
  • 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


Bortezomib (Velcade®). American Hospital Formulary Service (AHFS). AHFS Drug Information 2020. [Lexicomp Online Web site]. 03/04/2020. Available at: ​https://online.lexi.com/lco/action/home [via subscription only]. Accessed January 4, 2021.

Bortezomib (Velcade®). Elsevier Clinical Pharmacology Compendium. Indications/dosage [Clinical Key Web site]. 12/23/2020. Available at: https://www.clinicalkey.com/pharmacology/monograph/2794?sec=monindi&n=Velcade [via subscription only]. Accessed January 4, 2021.

Bortezomib (Velcade®). Lexi-Drugs Compendium. [Lexicomp Online Web site]. 12/23/2020. Available at: https://online.lexi.com/lco/action/home [via subscription only]. Accessed January 4, 2021.

Bortezomib (Velcade®). Micromedex® 2.0 Healthcare Series. DrugDex® [Micromedex® Web site]. 12/21/2020. Available at: https://www/micromedexsolutions.com/micromedex2/librarian [via subscription only]. Accessed January 4, 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.​

Horton TM, Lu X, O’Brien MM, et al. Bortezomib reinduction therapy to improve response rates in pediatric ALL in first relapse: A Children’s Oncology Group (COG) study (AALL07P1). J Clin Oncol. 2013;31(15 supp):10003.​​

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 - AIDS-Related Kaposi Sarcoma V3.2020. [NCCN Web site]. 07/15/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/kaposi.pdf [via subscription only]. Accessed January 4, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - B-cell Lymphomas V4.2020. [NCCN Web site]. 08/13/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdf [via subscription only]. Accessed January 4, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Multiple Myeloma V4.2021. [NCCN Web site]. 12/10/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf [via subscription only]. Accessed January 4, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Pediatric Acute Lymphoblastic Leukemia ​V2.2021. [NCCN Web site]. 10/22/2020. Available at: ​https://www.nccn.org/professionals/physician_gls/pdf/ped_all.pdf [via subscription only]. Accessed January 4, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Pediatric Hodgkin Lymphoma ​V2.2021. [NCCN Web site]. 10/21/2020. Available at: ​https://www.nccn.org/professionals/physician_gls/pdf/ped_hodgkin.pdf. [via subscription only]. Accessed January 4, 2021.​


National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Systemic Light Chain Amyloidosis V1.2021. [NCCN Web site]. 09/01/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/amyloidosis.pdf [via subscription only]. Accessed January 4, 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 January 4, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma. V1.2021. [NCCN Web site]. 09/01/2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/waldenstroms.pdf [via subscription only]. Accessed January 4, 2021.

National Comprehensive Cancer Network (NCCN). NCCN Drugs & Biologics Compendium™. Bortezomib. [NCCN Web site]. 2020. Available at: ​https://www.nccn.org/professionals/drug_compendium/content/contents.asp​ [via subscription only]. Accessed January 4, 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: ​https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2003/21602ltr.pdf. Accessed January 4, 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]. 07/2018. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=205004. Accessed January 4, 2021.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Bortezomib (Velcade®) prescribing information and approval letter. [FDA Web site]. 04/25/2019. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=021602. Accessed January 4, 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?event=overview.process&ApplNo=050718. Accessed January 4, 2021.


Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)


C81.10 Nodular sclerosis Hodgkin lymphoma, unspecified site
C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes
C81.13 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes
C81.14 Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.15 Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.16 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes
C81.17 Nodular sclerosis Hodgkin lymphoma, spleen
C81.18 Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites
C81.19 Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites
C81.20 Mixed cellularity Hodgkin lymphoma, unspecified site
C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes
C81.23 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes
C81.24 Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.25 Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.26 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes
C81.27 Mixed cellularity Hodgkin lymphoma, spleen
C81.28 Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites
C81.29 Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites
C81.30 Lymphocyte depleted Hodgkin lymphoma, unspecified site
C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes
C81.33 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes
C81.34 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.35 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.36 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes
C81.37 Lymphocyte depleted Hodgkin lymphoma, spleen
C81.38 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites
C81.39 Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites
C81.40 Lymphocyte-rich Hodgkin lymphoma, unspecified site
C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck
C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes
C81.43 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes
C81.44 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb
C81.45 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb
C81.46 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes
C81.47 Lymphocyte-rich Hodgkin lymphoma, spleen
C81.48 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites
C81.49 Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites
C83.00 Small cell B-cell lymphoma, unspecified site
C83.01 Small cell B-cell lymphoma, lymph nodes of head, face, and neck
C83.02 Small cell B-cell lymphoma, intrathoracic lymph nodes
C83.03 Small cell B-cell lymphoma, intra-abdominal lymph nodes
C83.04 Small cell B-cell lymphoma, lymph nodes of axilla and upper limb
C83.05 Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb
C83.06 Small cell B-cell lymphoma, intrapelvic lymph nodes
C83.07 Small cell B-cell lymphoma, spleen
C83.08 Small cell B-cell lymphoma, lymph nodes of multiple sites
C83.09 Small cell B-cell lymphoma, extranodal and solid organ sites
C83.10 Mantle cell lymphoma, unspecified site
C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck
C83.12 Mantle cell lymphoma, intrathoracic lymph nodes
C83.13 Mantle cell lymphoma, intra-abdominal lymph nodes
C83.14 Mantle cell lymphoma, lymph nodes of axilla and upper limb
C83.15 Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
C83.16 Mantle cell lymphoma, intrapelvic lymph nodes
C83.17 Mantle cell lymphoma, spleen
C83.18 Mantle cell lymphoma, lymph nodes of multiple sites
C83.19 Mantle cell lymphoma, extranodal and solid organ sites
C88.0 Waldenström macroglobulinemia
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C90.10 Plasma cell leukemia not having achieved remission
C90.11 Plasma cell leukemia in remission
C90.12 Plasma cell leukemia in relapse
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.02 Acute lymphoblastic leukemia, in relapse
C91.50 Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission
C91.52 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse
D47.Z2 Castleman disease
E85.81  Light chain (AL) amyloidosis

 
FOR AIDS-RELATED KAPOSI SARCOMA COVERAGE BOTH DIAGNOSES ARE REQUIRED:

B20 Human immunodeficiency virus [HIV] disease 

AND ONE OF THE FOLLOWING DIAGNOSIS CODES:
C46.0   Kaposi's sarcoma of skin
C46.1   Kaposi's sarcoma of soft tissue
C46.2   Kaposi's sarcoma of palate
C46.3   Kaposi's sarcoma of lymph nodes
C46.4   Kaposi's sarcoma of gastrointestinal sites
C46.50 Kaposi's sarcoma of unspecified lung
C46.51 Kaposi's sarcoma of right lung
C46.52 Kaposi's sarcoma of left lung
C46.7   Kaposi's sarcoma of other sites
C46.9   Kaposi's sarcoma, unspecified​
 



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

N/A​

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

4/12/2021
4/19/2021
MA08.037
Medical Policy Bulletin
Medicare Advantage
No