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
Palonosetron (Aloxi) may be considered medically necessary in individuals 18 years of age and older whenANYof the following criteria are met:
- Prevention of chemotherapy induced nausea or vomiting associated with low or minimally emetogenic cancer chemotherapy for members who have a treatment failure or contraindication to granisetron and ondansetron;or
- Prevention of acute and delayed nausea and vomiting associated with initial and repeat courses for moderately emetogenic cancer chemotherapy;or
- Prevention of acute nausea and vomiting associated with initial and repeat courses for highly emetogenic cancer chemotherapy;or
- Prevention of postoperative nausea and vomiting (PONV) for up to 24 hours following surgery, and there is a treatment failure or contraindication to ondansetron.
Palonosetron (Aloxi) may be considered medically necessary for pediatric individuals 1 month of age to less than 17 years for:
- Prevention of acute nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including highly emetogenic cancer chemotherapy.
National Comprehensive Cancer Network (NCCN) Approved Recommendations
Palonosetron (Aloxi) may be considered medically necessary when used in combination with dexamethasone before intravenous antineoplastic therapy with:
- High emetic risk with either aprepitant, fosaprepitant, or rolapitant;or
- High emetic risk with olanzapine and either aprepitant, fosaprepitant, or rolapitant;or
- High or moderate emetic risk with olanzapine;or
- Moderate emetic risk (preferred); or
- Moderate emetic risk with either aprepitant, fosaprepitant, or rolapitant for individuals with additional risk factors or previous treatment failure with a corticosteroid and 5HT3 receptor antagonist alone.
Note: May use with or without lorazepam, histamine-2 blockers, or proton pump inhibitors.
Palonosetron (Aloxi) injection performed for indications other than those listed above will be denied as not medically necessary.
Procedure Codes
