Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Panitumumab (
Vectibix)
may be considered medically necessary for the treatment of metastatic colorectal cancer (mCRC) when the following are met:
-
Individuals with wild-type RAS (defined as wild-type in both KRAS and NRAS) mCRC as determined by an FDA-approved test as
ANY
of the following:
-
First-line therapy in conjunction with FOLFOX (fluorouracil, leucovorin, and oxaliplatin);
or
-
Monotherapy following disease progression after prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy;
or
Compendia Sources
Panitumumab (Vectibix) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of panitumumab (Vectibix) 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
