Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the
www.fepblue.org
website.
The use of bendamustine (Treanda, Bendeka, Belrapzo, Vivimusta) may be considered medically necessary for the following conditions:
Chronic Lymphocytic Leukemia (CLL)
-
As treatment of individuals with CLL;
or
Non-Hodgkin Lymphoma (NHL)
-
Indolent B-cell NHL as therapy that has progressed during or within six months of treatment with rituximab or a rituximab-containing regimen;
or
Compendia Sources
- Bendamustine (Treanda, Bendeka, Belrapzo, Vivimusta) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of bendamustine (Treanda, Bendeka, Belrapzo, Vivimusta) 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
J9033 | J9034 | J9036 | J9056 | J9058 | J9059 |
NOTE:
In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.
Diagnosis Codes
Covered Diagnosis codes for Procedure Codes J9033, J9034, J9036, J9056, J9058 and J9059
C81.00 | C81.01 | C81.02 | C81.03 | C81.04 | C81.05 | C81.06 |
C81.07 | C81.08 | C81.09 | C81.10 | C81.11 | C81.12 | C81.13 |
C81.14 | C81.15 | C81.16 | C81.17 | C81.18 | C81.19 | C81.20 |
C81.21 | C81.22 | C81.23 | C81.24 | C81.25 | C81.26 | C81.27 |
C81.28 | C81.29 | C81.30 | C81.31 | C81.32 | C81.33 | C81.34 |
C81.35 | C81.36 | C81.37 | C81.38 | C81.39 | C81.40 | C81.41 |
C81.42 | C81.43 | C81.44 | C81.45 | C81.46 | C81.47 | C81.48 |
C81.49 | C81.70 | C81.71 | C81.72 | C81.73 | C81.74 | C81.75 |
C81.76 | C81.77 | C81.78 | C81.79 | C81.90 | C81.91 | C81.92 |
C81.93 | C81.94 | C81.95 | C81.96 | C81.97 | C81.98 | C81.99 |
C82.00 | C82.01 | C82.02 | C82.03 | C82.04 | C82.05 | C82.06 |
C82.07 | C82.08 | C82.09 | C82.10 | C82.11 | C82.12 | C82.13 |
C82.14 | C82.15 | C82.16 | C82.17 | C82.18 | C82.19 | C82.20 |
C82.21 | C82.22 | C82.23 | C82.24 | C82.25 | C82.26 | C82.27 |
C82.28 | C82.29 | C82.30 | C82.31 | C82.32 | C82.34 | C82.35 |
C82.36 | C82.37 | C82.38 | C82.39 | C82.40 | C82.41 | C82.42 |
C82.43 | C82.44 | C82.45 | C82.46 | C82.47 | C82.48 | C82.49 |
C82.50 | C82.51 | C82.52 | C82.53 | C82.54 | C82.55 | C82.56 |
C82.57 | C82.58 | C82.59 | C82.60 | C82.61 | C82.62 | C82.63 |
C82.64 | C82.65 | C82.66 | C82.67 | C82.68 | C82.69 | C82.80 |
C82.81 | C82.82 | C82.83 | C82.84 | C82.85 | C82.86 | C82.87 |
C82.88 | C82.89 | C82.90 | C82.92 | C82.93 | C82.94 | C82.95 |
C82.96 | C82.97 | C82.98 | C82.99 | C83.00 | C83.01 | C83.02 |
C83.03 | C83.04 | C83.05 | C83.06 | C83.07 | C83.08 | C83.09 |
C83.10 | C83.11 | C83.12 | C83.13 | C83.14 | C83.15 | C83.16 |
C83.17 | C83.18 | C83.19 | C83.30 | C83.31 | C83.32 | C83.33 |
C83.34 | C83.35 | C83.36 | C83.37 | C83.38 | C83.390 | C83.398 |
C83.51 | C83.52 | C83.53 | C83.54 | C83.55 | C83.56 | C83.57 |
C83.58 | C83.59 | C83.80 | C83.81 | C83.82 | C83.83 | C83.84 |
C83.85 | C83.86 | C83.87 | C83.88 | C83.89 | C83.90 | C83.91 |
C83.92 | C83.93 | C83.94 | C83.95 | C83.96 | C83.97 | C83.98 |
C83.99 | 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 |
C84.40 | C84.41 | C84.42 | C84.43 | C84.44 | C84.45 | C84.46 |
C84.47 | C84.48 | C84.49 | C84.60 | C84.61 | C84.62 | C84.63 |
C84.64 | C84.65 | C84.66 | C84.67 | C84.68 | C84.69 | C84.70 |
C84.71 | C84.72 | C84.73 | C84.74 | C84.75 | C84.76 | C84.77 |
C84.78 | C84.79 | C84.7A | C84.90 | C84.91 | C84.92 | C84.93 |
C84.94 | C84.95 | C84.96 | C84.97 | C84.98 | C84.99 | C84.Z0 |
C84.Z1 | C84.Z2 | C84.Z3 | C84.Z4 | C84.Z5 | C84.Z6 | C84.Z7 |
C84.Z8 | C84.Z9 | C85.10 | C85.11 | C85.12 | C85.13 | C85.14 |
C85.15 | C85.16 | C85.17 | C85.18 | C85.19 | C85.20 | C85.21 |
C85.22 | C85.23 | C85.24 | C85.25 | C85.26 | C85.27 | C85.28 |
C85.29 | C85.80 | C85.81 | C85.82 | C85.83 | C85.84 | C85.85 |
C85.86 | C85.87 | C85.88 | C85.89 | C86.10 | C86.20 | C86.50 |
C88.00 | C88.40 | C88.41 | C90.00 | C90.02 | C90.10 | C90.12 |
C90.20 | C90.22 | C90.30 | C90.32 | C91.10 | C91.12 | C91.50 |
C91.52 | D47.Z1 | E85.3 | E85.4 | E85.81 | E85.89 | E85.9 |
Diagnosis Code B20 covered when billed with ANY ONE of the following diagnosis codes
C83.30 | C83.31 | C83.32 | C83.33 | C83.34 | C83.35 | C83.36 |
C83.37 | C83.38 | C83.390 | C83.398 | C83.80 | C83.81 | C83.82 |
C83.83 | C83.84 | C83.85 | C83.86 | C83.87 | C83.88 | C83.89 |
C85.80 | C85.81 | C85.82 | C85.83 | C85.84 | C85.85 | C85.86 |
C85.87 | C85.88 | C85.89 |
