Ixabepilone (Ixempra)

Section: Injections
Effective Date: June 01, 2020
Revised Date: May 11, 2020
Last Reviewed: May 19, 2020

Description

The principal pharmacologic action of Ixabepilone (Ixempra®) in cancer patients is halting cell division by inhibiting microtubules in the mitotic phase, leading to cell death. Ixabepilone (Ixempra) also demonstrates synergistic antitumor activity in combination with capecitabine in vivo.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

Food and Drug Administration (FDA) Indications

Ixabepilone (Ixempra) may be considered medically necessary when ANY ONE of the following criteria is met:

  • Breast cancer, locally advanced or metastatic, as monotherapy in individuals whose tumors are resistant or refractory to anthracyclines, taxanes, and capecitabine; or
  • Breast cancer, locally advanced or metastatic, in combination with capecitabine in individuals who are taxane- or anthracycline-resistant, or taxane-resistant with a contraindication to anthracyclines.

Ixabepilone (Ixempra) is considered experimental/investigational forall other indications and therefore, non-covered. Scientific evidence does notsupport the use for any other indications than those listed above.

Procedure Codes

J9207

National Comprehensive Cancer Network (NCCN) Recommendations

Ixabepilone (Ixempra) may be considered medically necessary when ANY ONE of the following criteria is met:

  • As a single agent for recurrent or metastatic breast cancer human epidermal growth factor receptor 2 (HER2)-negative disease:
    • With symptomatic visceral disease or visceral crisis; or
    • That is hormone receptor-negative or hormone receptor-positive and endocrine therapy refractory; or
  • Therapy in combination with trastuzumab (Herceptin®) for HER2-positive recurrent or metastatic trastuzumab (Herceptin)-exposed disease
    • With symptomatic visceral disease or visceral crisis; or
    • That is hormone receptor-negative or hormone receptor-positive and endocrine therapy refractory.

Ixabepilone (Ixempra) is considered experimental/investigational for all other indications and therefore, non-covered. Scientific evidence does not support the use for any other indications than those listed above.

Procedure Codes

J9207

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J9207:

 

C50.011

C50.012

C50.019

C50.021

C50.022

C50.029

C50.111

C50.112

C50.119

C50.121

C50.122

C50.129

C50.211

C50.212

C50.219

C50.221

C50.222

C50.229

C50.311

C50.312

C50.319

C50.321

C50.322

C50.329

C50.411

C50.412

C50.419

C50.421

C50.422

C50.429

C50.511

C50.512

C50.519

C50.521

C50.522

C50.529

C50.611

C50.612

C50.619

C50.621

C50.622

C50.629

C50.811

C50.812

C50.819

C50.821

C50.822

C50.829

C50.911

C50.912

C50.919

C50.921

C50.922

C50.929

C61

Z85.3

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Original Effective Date June 1, 2020

Internal Medical Policy Committee 5-19-2020 Adopt new pre-certification policy

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.