Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Brentuximab vedotin (Adcetris) may be considered medically necessary for
ANY
of the following conditions:
Classical Hodgkin Lymphoma (cHL)
-
Treatment of individuals with previously untreated Stage III or IV cHL, in combination with doxorubicin, vinblastine, and dacarbazine;
or
-
Treatment of individuals with cHL at high risk of relapse or progression as post-autologous hematopoietic stem cell transplantation (auto-HSCT) consolidation;
or
-
Treatment of individuals with cHL after failure of auto-HSCT or after failure of at least two prior multi agent chemotherapy regimens in individuals who are not auto-HSCT candidates;
or
-
Treatment of individuals 2 years and older with previously untreated high risk cHL, in combination with doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide;
or
Primary Cutaneous Anaplastic Large Cell Lymphoma (pcALCL)
-
Treatment of individuals with pcALCL or CD30- expressing mycosis fungoides (MF) who have received prior systemic therapy;
or
Systemic Anaplastic Large Cell Lymphoma (sALCL)
-
Treatment of individuals with previously untreated sALCL or other CD30-expressing peripheral T-cell lymphomas (PTCL), including angioimmunoblastic T-cell lymphoma and PTCL not otherwise specified, in combination with cyclophosphamide, doxorubicin, and prednisone;
or
-
Treatment of individuals with sALCL after failure of at least one prior multi-agent chemotherapy regimen;
or
Large B-Cell Lymphoma (LBCL)
- Treatment of individuals with relapsed or refractory LBCL, including diffuse large B-cell lymphoma (DLBCL) NOS, DLBCL arising from indolent lymphoma, or high-grade B-cell lymphoma (HGBL), after two or more lines of systemic therapy who are not eligible for auto-HSCT or CAR T-cell therapy, in combination with lenalidomide and a rituximab product; or
Compendia Sources
Brentuximab vedotin (Adcetris) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of brentuximab vedotin (Adcetris) 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
