Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Cetuximab (Erbitux) may be considered medically necessary for the following:
Colorectal Cancer
- As treatment of KRAS wild-type, EGFR-expressing, metastatic colorectal cancer as determined by an FDA-approved test in ANY of the following:
- In combination with FOLFIRI (irinotecan, fluorouracil, leucovorin) for first-line treatment; or
- In combination with irinotecan in individuals who are refractory to irinotecan-based chemotherapy; or
- As a single agent in individuals who have failed oxaliplatin- and irinotecan-based chemotherapy or who are intolerant to irinotecan; or
Head and Neck Cancer
- As treatment in combination with radiation therapy for the initial treatment of locally or regionally advanced squamous cell carcinoma of the head and neck (SCCHN); or
- As treatment in combination with platinum-based therapy with fluorouracil for the first-line treatment of individuals with recurrent locoregional disease or metastatic SCCHN; or
- As a single agent for the treatment of individuals with recurrent or metastatic SCCHN for whom prior platinum-based therapy has failed; or
Compendia Sources
Cetuximab (Erbitux) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of cetuximab (Erbitux) 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.
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