Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Denileukin diftitox-cxdl (Lymphir) may be considered medically necessary when ALL the following criteria are met:
-
Individual is 18 years of age or older;
and
-
Individual has relapsed or refractory Stage I-III cutaneous T-cell lymphoma (CTCL);
and
- Individual had at least one prior systemic therapy.
Compendia Sources
Denileukin diftitox-cxdl (Lymphir) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of denileukin diftitox-cxdl (Lymphir) 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
Diagnosis Codes
Covered Diagnosis Codes for Denileukin diftitox-cxdl (Lymphir)
C84.00 | C84.01 | C84.02 | C84.03 | C84.04 | C84.05 | C84.06 |
C84.07 | C84.08 | C84.09 | C84.10 | C84.11 | C84.12 | C84.13 |
C84.14 | C84.15 | C84.16 | C84.17 | C84.18 | C84.19 |
