Crizanlizumab-tmca (Adakveo) (ARCHIVED)

Policy ID: I-218-009

Section: Injections

Effective Date: February 01, 2020

Revised Date: October 16, 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**This policy has been Archived effective December 08, 2024.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-218-009

Section: Injections

Effective Date: February 01, 2020

Revised Date: October 16, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Archived Date: December 08, 2024

Applies To: Commercial Only

Description

Crizanlizumab (Adakveo®) is a humanized IgG2 kappa monoclonal antibody that functions by binding to P-selectin, preventing the interaction with P-selectin glycoprotein ligand 1. Blocking P-selectin on the surface of activated endothelium and platelets blocks interactions between endothelial cells, platelets, red blood cells, and leukocytes, which in turn reduces the frequency of vaso-occlusive crises (VOCs) in individuals with sickle cell disease.

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 crizanlizumab (Adakveo) may be considered medically necessary to reduce the frequency of VOCs in sickle cell disease when the individual meets ALL of the following criteria:

The individual is 16 years of age or older; and
The individual has a diagnosis of sickle cell disease; and
The individual has a history of VOCs and either ONE (1) of the following:
- The individual is currently receiving hydroxyurea therapy, and hydroxyurea therapy will continue with the addition of crizanlizumab (Adakveo); or
- The individual has experienced a therapeutic failure, intolerance, or contraindication to hydroxyurea therapy.

Reauthorization Criteria

Continuation of therapy with crizanlizumab (Adakveo) may be considered medically necessary when the following criteria are met:

The individual meets all above criteria; and
Provider attestation that individual has demonstrated a disease stability or beneficial response to therapy.

The use of crizanlizumab (Adakveo) for any other indication is considered experimental/investigational and therefore, non-covered. The safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.

Procedure Code

J0791

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

NOTE: Crizanlizumab (Adakveo) is not to be used in combination with voxelotor (Oxbryta).

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes J0971

D57.00

D57.01

D57.02

D57.03

D57.04

D57.09

D57.1

D57.20

D57.211

D57.212

D57.213

D57.214

D57.218

D57.219

D57.40

D57.411

D57.412

D57.413

D57.414

D57.418

D57.419

D57.42

D57.431

D57.432

D57.433

D57.434

D57.438

D57.439

D57.44

D57.451

D57.452

D57.453

D57.454

D57.458

D57.459

D57.80

D57.811

D57.812

D57.813

D57.814

D57.818

D57.819

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 New Policy for North Dakota

Internal Medical Policy Committee 3-16-2020

Added new code C9053, and
Added additional diagnosis codes

Internal Medical Policy Committee 7-22-2020 - Effective July 01, 2020

Removed C9053, and
Added new code, J0791

Internal Medical Policy Committee 9-21-2020 Updated diagnosis codes

Internal Medical Policy Committee 11-19-2020 No clinical content change

Internal Medical Policy Committee 3-17-2021 Annual review, no clinical content change

Internal Medical Policy Committee 3-23-2022 Annual review no clinical content change

Internal Medical Policy Committee 9-28-2022

Added reauthorization criteria, and
Added note: 'Crizanlizumab (Adakveo) is not to be used in combination with voxelotor (Oxbryta).'
Updated experimental/investigational statement

Internal Medical Policy Committee 9-12-2023

Annual review, no clinical content change

Internal Medical Policy Committee 11-15-2023 Effective October 01, 2023

Added diagnosis codes D57.04, D57.214, D57.414, D57.434, D57.454 and D57.814

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.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search