Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Loncastuximab tesirine-lpyl (Zynlonta) may be considered medically necessary in individuals 18 years and older when the following criteria are met:
- Individual has relapsed or refractory large B cell lymphoma (e.g., diffuse large B-cell lymphoma not otherwise specified, diffuse large B-cell lymphoma arising from low grade lymphoma, high-grade-B-cell lymphoma); and
- Individual has had disease progression on or after two (2) or more different lines of chemotherapy; or
Compendia Sources
Loncastuximab tesirine-lpyl (Zynlonta) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of loncastuximab tesirine-lpyl (Zynlonta) 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
