Carfilzomib (Kyprolis) (ARCHIVED)

Policy ID: I-41-011

Section: Injections

Effective Date: July 01, 2018

Revised Date: October 25, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Applies To: Commercial Only

This policy has been Archived effective December 08, 2024. Click the Archive tab above for more information.

Policy ID: I-41-011

Section: Injections

Effective Date: July 01, 2018

Revised Date: October 25, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Archived Date: December 08, 2024

Applies To: Commercial Only

Description

Carfilzomib (Kyprolis®) is a targeted therapy drug and is classified as a proteasome inhibitor. It exhibits antiproliferative and proapoptotic activity in sold and hematologic tumor cells.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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.

Carfilzomib (Kyprolis) may be considered medically necessary when the following criteria have been met:

Multiple Myeloma

For the treatment of individuals with relapsed or refractory multiple myeloma who have received one to three lines of therapy in combination with ANY of the following:
- Lenalidomide and dexamethasone; or
- Dexamethasone; or
- Daratumumab and dexamethasone; or
- Daratumumab and hyaluronidase-fihj and dexamethasone; or
- Isatuximab and dexamethasone; or
As a single agent for the treatment of individuals with relapsed or refractory multiple myeloma who have received one or more lines of therapy; or

Compendia Sources

Carfilzomib (Kyprolis) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.

The use of carfilzomib (Kyprolis) 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

J9047

NOTE: In addition to the above criteria, product specific 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

C88.0

C90.00

C90.02

C90.10

C90.12

C90.20

C90.22

C90.30

C90.32

E85.3

E85.4

E85.81

E85.89

E85.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019

Updated codes

Internal Medical Policy Committee 11-19-2020

Updated FDA indications to also include regimen with daratumumab plus dexamethasone, and
Updated NCCN recommendations

Internal Medical Policy Committee 7-22-2021

Updated NCCN recommendations, and
Updated diagnosis codes

Internal Medical Policy Committee 7-21-2022

Added additional diagnosis codes, and
Removed diagnosis code Z85.79, and
Removed NCCN recommendations and added this statement 'Carfilzomib (Kyprolis) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.', and
Updated the experimental/investigational statement

Internal Medical Policy Committee 7-26-2023 - Effective September 01, 2023

Added diagnosis codes E85.3 and E85.4 to the policy

Internal Medical Policy Committee 7-16-2024 Effective September 01, 2024

Updated multiple myeloma criteria

Internal Medical Policy Committee 11-19-2024 Effective December 08, 2024

Archived policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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