Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Mogamulizumab-kpkc (Poteligeo) may be considered medically necessary when the following criteria are met:
-
Individual is 18 years of age or older;
and
-
Treatment is for relapsed or refractory mycosis fungoides (MF) or Sezary syndrome (SS);
and
-
Individual has received at least one prior systemic therapy;
or
Compendia Sources
Mogamulizumab (Poteligeo) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of mogamulizumab-kpkc (Poteligeo) 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
