Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Blinatumomab (Blincyto) may be considered medically necessary as treatment of adult and pediatric patients 1 (one) month and older for
ANY
of the following indications:
-
Relapsed or refractory CD19-positive B-cell precursor acute lymphoblastic leukemia (ALL);
or
-
CD19-positive B-cell precursor ALL in first or second complete remission with minimal residual disease (MRD) greater than or equal to 0.1%;
or
- CD19-positive Philadelphia chromosome-negative B-cell precursor ALL in the consolidation phase of multiphase chemotherapy
Compendia Sources
Blinatumomab (Blincyto) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of blinatumomab (Blincyto) 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 Code
