Pegfilgrastim-jmdb (Fulphila), pegfilgrastim-bmez (Ziextenzo), pegfilgrastim-cbqv (Udenyca), pegfilgrastim-apgf (Nyvepria), pegfilgrastim-fgpk (Stimufend), pegfilgrastim-pbbk (Fylnetra) and eflapegrastim-xnst (Rolvedon) may be considered medically necessary for
ANY
the following:
-
To decrease the incidence of infection as manifested by febrile neutropenia in individuals with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant incidence of severe neutropenia with fever;
or
Compendia Sources
Pegfilgrastim-jmdb (Fulphila), pegfilgrastim-bmez (Ziextenzo), pegfilgrastim-cbqv (Udenyca), pegfilgrastim-apgf (Nyvepria), pegfilgrastim-fgpk (Stimufend), and pegfilgrastim-pbbk (Fylnetra) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
Note:
Pegfilgrastim-jmdb (Fulphila), pegfilgrastim-bmez (Ziextenzo), pegfilgrastim-cbqv (Udenyca), pegfilgrastim-apgf (Nyvepria) pegfilgrastim-fgpk (Stimufend), pegfilgrastim-pbbk (Fylnetra), and eflapegrastim-xnst (Rolvedon) are not indicated for the mobilization or peripheral blood progenitor cells for hematopoietic stem cell transplantation.
Pegfilgrastim-jmdb (Fulphila), pegfilgrastim-bmez (Ziextenzo), pegfilgrastim-cbqv (Udenyca), pegfilgrastim-apgf (Nyvepria), pegfilgrastim-fgpk (Stimufend), or pegfilgrastim-pbbk (Fylnetra) not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
J1449 | Q5108 | Q5111 | Q5120 | Q5122 | Q5127 | Q5130 |