Daratumumab (Darzalex) and Daratumumab and Hyaluronidase-fihj (Darzalex Faspro) (Medicaid Expansion)

Policy ID: ME-I-150-012-01

Section: Injections

Effective Date: December 09, 2024

Last Reviewed: November 19, 2024

Applies To: Medicaid Expansion Only

Description

Daratumumab (Darzalex™) is an immunoglobulin G1 kappa (IgG1k) human monoclonal antibody against CD38 antigen indicated for the treatment of individuals with multiple myeloma.

Hyaluronan is a polysaccharide found in the extracellular matrix of the subcutaneous tissue. It is depolymerized by the naturally occurring enzyme hyaluronidase. Unlike the stable structural components of the interstitial matrix, hyaluronan has a half-life of approximately 0.5 days. Hyaluronidase increases permeability of the subcutaneous tissue by depolymerizing hyaluronan. In the doses administered, hyaluronidase in daratumumab and hyaluronidase-fihj (Darzalex Faspro^TM) acts locally. The effects of hyaluronidase are reversible and permeability of the subcutaneous tissue is restored within 24 to 48 hours.

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.

Daratumumab (Darzalex)

Daratumumab (Darzalex) may be considered medically necessary for the treatment of multiple myeloma in individuals 18 years of age or older who meet ANY of the following criteria:

As combination therapy with lenalidomide and dexamethasone in newly diagnosed individuals who are ineligible for autologous stem cell transplant; or
As combination therapy with lenalidomide and dexamethasone in individuals with relapsed or refractory disease who have received at least one (1) prior therapy; or
As combination therapy with bortezomib, melphalan and prednisone in newly diagnosed individuals who are ineligible for autologous stem cell transplant; or
As combination therapy with bortezomib, thalidomide, and dexamethasone in newly diagnosed individuals who are eligible for autologous stem cell transplant; or
As combination therapy with dexamethasone and bortezomib in individuals who have received at least one (1) prior therapy; or
As combination therapy with pomalidomide and dexamethasone in individuals who have received at least two (2) prior therapies including lenalidomide and a proteasome inhibitor; or
As monotherapy, in individuals who have received at least three (3) prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent; or
As combination therapy with carfilzomib and dexamethasone in individuals with relapsed or refractory disease who have received one (1) to three (3) prior lines of therapy.

The use of daratumumab (Darzalex) 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

J9145

Daratumumab and Hyaluronidase-fihj (Darzalex Faspro)

Daratumumab and hyaluronidase-fihj (Darzalex Faspro) may be considered medically necessary for the treatment of individuals 18 years of age or older with multiple myeloma who meet ANY of the following criteria:

As combination therapy with bortezomib, melphalan and prednisone in newly diagnosed individuals who are ineligible for autologous stem cell transplant; or
As combination therapy with lenalidomide and dexamethasone in newly diagnosed individuals who are ineligible for autologous stem cell transplant; or
As combination therapy with lenalidomide and dexamethasone in individuals with relapsed or refractory multiple myeloma who have received at least one (1) prior therapy; or
As combination therapy with bortezomib and dexamethasone in individuals who have received at least one prior therapy; or
As combination therapy with pomalidomide and dexamethasone in individuals who have received at least one (1) prior therapy including lenalidomide and a proteasome inhibitor; or
As combination therapy with carfilzomib and dexamethasone in individuals with relapsed or refractory disease who have received one (1) to three (3) prior lines of therapy; or
As monotherapy, in individuals who have received at least three (3) prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent; or
In combination with bortezomib, thalidomide and dexamethasone in newly diagnosed individuals who are eligible for autologous stem cell transplant; or
In combination with bortezomib, lenalidomide, and dexamethasone for induction and consolidation in newly diagnosed patients who are eligible for autologous stem cell transplant; or

Daratumumab and hyaluronidase-fihj (Darzalex Faspro) may be considered medically necessary for the treatment of light chain (AL) amyloidosis in individuals 18 years of age or older who meet the following criteria:

As combination therapy with bortezomib, cyclophosphamide and dexamethasone in newly diagnosed individuals.

The use of daratumumab and hyaluronidase-fihj (Darzalex Faspro) 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

J9144

Compendia Sources

Daratumumab (Darzalex) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

The use of daratumumab (Darzalex) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) 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 Codes

J9144

J9145

NOTE: In addition to the above criteria, product specific dosage 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.

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.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes J9144 and J9145

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

Additional Covered Diagnosis Codes for Procedure Codes J9145

C83.50

C83.51

C83.52

C83.53

C83.54

C83.55

C83.56

C83.57

C83.58

C83.59

C91.00

C91.01

C91.02

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2024 Effective December 09, 2024

Adopted Medicaid Expansion specific 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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