ND Committee Review
Internal Medical Policy Committee 5-15-2019 Adopted policy
Internal Medical Policy Committee 7-22-2020 Annual review,
- Changed
procedure code J9313 to precertification drug;
and
- Removed
renal function criteria
Internal Medical Policy Committee 7-22-2021 Annual review, no clinical content change
Internal Medical Policy Committee 3-23-2022
- Removed
NCCN recommendations;
and
- Added
this statement 'Moxetumomab pasudotox-tdfk (Lumoxiti) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.';
and
- Updated
experimental/investigational statement
Internal Medical Policy Committee 3-23-2023 Annual review, no clinical content change
Internal Medical Policy Committee 7-26-2023 -
Effective September 01, 2023
- Updated
order of the criteria, no clinical content change
- Updated
experimental/investigational statement