ND Committee Review
Internal Medical Policy Committee 9-26-2019
Adopted
new policy
Internal Medical Policy Committee 11-14-2019
Added
18 years of age or older to criteria
Internal Medical Policy Committee 5-19-2020
Changed
J9145 to pre-certification drug
Internal Medical Policy Committee 7-22-2020
- Added
daratumumab and hyaluronidase-fihj (Darzalex Faspro) to policy,
and
- Added
one additional daratumumab (Darzalex) FDA indication to policy
Internal Medical Policy Committee 9-21-2020
Added
new code, C9062, to policy
Internal Medical Policy Committee 1-19-2021 -
Effective January 01, 2021
- Removed
C9062,
and
- Added
new code J9144
Internal Medical Policy Committee 5-21-2021
- Updated
FDA indications
and
- Updated
NCCN recommendations for daratumumab (Darzalex) and daratumumab and hyaluronidase-fihj (Darzalex Faspro)
Internal Medical Policy Committee 5-24-2022 Annual review, no clinical content change
Internal Medical Policy Committee 9-28-2022
- Removed
NCCN recommendations,
and
- Added
this statement 'Daratumumab (Darzalex) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.',
and
- Updated
experimental/investigational statement,
and
- Added
'
NOTE:
Darzalex Faspro is not indicated and is not recommended for the treatment of individuals with light chain (AL) amyloidosis who have NYHA Class IIIB or Class IV cardiac disease or Mayo Stage IIIB outside of controlled clinical trials.',
and
- Added
additional criteria for Darzalex Faspro,
and
- Removed
diagnosis codes Z85.79
Internal Medical Policy Committee 9-12-2023 -
Effective September 01, 2023
- Added
diagnosis codes E85.3 and E85.4 for J9144 and J9145
- Removed
diagnosis code D47.2 for J9144 and J9145
- Updated
experimental/investigational statement
Internal Medical Policy Committee 9-17-2024
Effective November 01, 2024
- Annual review
no clinical content change
Internal Medical Policy Committee 11-19-2024
Effective December 08, 2024