Criteria
Coverage is subject to the specific terms of the member's benefit plan.
The use of amivantamab-vmjw (Rybrevant) may be considered medically necessary for individuals 18 years or older when ALL of the following criteria are met:
Non-Small Cell Lung Cancer
- Individual diagnosed with locally advanced or metastatic non- small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations and treatment is used as one of the following:
- Single agent for disease progression while on or after platinum-based chemotherapy; or
- First line or in combination with carboplatin and pemetrexed; or
- Individual diagnosed with locally advanced or metastatic non- small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 L858R substitution mutations and treatment is used first line in combination with lazertinib; or
Compendia Sources
Amivantamab-vmjw (Rybrevant) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of amivantamab-vmjw (Rybrevant) for any indication not listed on this policy is considered experimental/investigational, and therefore, not covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Code
