Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Denileukin diftitox-cxdl (Lymphir) may be considered medically necessary when ALL the following criteria are met:
- Individual is 18 years of age or older; and
- Individual has relapsed or refractory Stage I-III cutaneous T-cell lymphoma (CTCL); and
- Individual had at least one prior systemic therapy.
Compendia Sources
Denileukin diftitox-cxdl (Lymphir) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of denileukin diftitox-cxdl (Lymphir) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure codes
Diagnosis Codes
Covered Diagnosis Codes for Denileukin diftitox-cxdl (Lymphir)
C84.00
| C84.01
| C84.02
| C84.03
| C84.04
| C84.05
| C84.06
|
C84.07
| C84.08
| C84.09
| C84.10
| C84.11
| C84.12
| C84.13
|
C84.14
| C84.15
| C84.16
| C84.17
| C84.18
| C84.19
|
