Necitumumab (Portrazza) (ARCHIVED)

Necitumumab (Portrazza)

Policy ID: I-168-006

Section: Injections

Effective Date: October 01, 2019

Revised Date: December 09, 2022

Revision Effective Date: December 31, 2022

Last Reviewed: November 29, 2022

Applies To: Commercial and Medicaid Expansion

This policy has been Archived Effective December 31, 2022. Click the Archive tab above for more information.

Policy ID: I-168-005

Section: Injections

Effective Date: October 01, 2019

Revised Date: September 02, 2020

Revision Effective Date: October 01, 2020

Last Reviewed: January 20, 2022

Archived Date: December 31, 2022

Applies To: Commercial and Medicaid Expansion

Description

Necitumumab (Portrazza™) is a recombinant human IgG1 monoclonal antibody that binds to the human epidermal growth factor receptor (EGFR) and blocks the binding of EGFR to its ligands. Expression and activation of EGFR has been correlated with malignant progression, induction of angiogenesis and inhibition of apoptosis.

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.

Necitumumab (Portrazza) may be considered medically necessary in combination with gemcitabine and cisplatin as first-line treatment of individuals 18 years of age or older with metastatic squamous non-small cell lung cancer (NSCLC).

Necitumumab (Portrazza) is considered experimental/investigational for any other indication and therefore, non-covered. Scientific evidence does not support its use for any other indications.

Procedure Codes

J9295

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.

Diagnosis Codes

Covered diagnosis codes for procedure code J9295

C34.00

C34.01

C34.02

C34.10

C34.11

C34.12

C34.2

C34.30

C34.31

C34.32

C34.80

C34.81

C34.82

C34.90

C34.91

C34.92

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 Adopted policy

Internal Medical Policy Committee 9-21-2020 Annual review, no clinical content change

Internal Medical Policy Committee 9-21-2021 Annual review

Internal Medical Policy Committee 1-20-2022 No clinical content change

Internal Medical Policy Committee 11-29-2022 Archiving - Effective December 31, 2022

Links

References (PDF)

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.

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