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