Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Axatilimab-csfr (Niktimvo) may be considered medically necessary when
ALL
of the following criteria are met:
Chronic Graft-Versus-Host Disease
-
Individual weighs at least 40 kg;
and
-
Individual has been diagnosed with chronic graft-versus-host disease (GVHD);
and
-
Individual has experienced treatment failure of at least two (2) different systemic therapies;
and
- Initial authorization is for six (6) months.
Reauthorization Criteria
Continuation of axatilimab-csfr (Niktimvo) may be medically necessary for individuals when the following criteria are met:
-
Individual demonstrates a clinically meaningful decrease in their chronic GVHD symptoms but has not yet had full resolution of abnormalities;
and
- Reauthorization will be for a period of six (6) months.
The use of axatilimab-csfr (Niktimvo) 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
