ND Committee Review
Internal Medical Policy Committee 1-22-2020 updated description, added additional NCCN indications, updated dx codes and references, will require pre-certification as of 2/1/2020
Internal Medical Policy Committee 1-19-2021 updated NCCN recommendations
Internal Medical Policy Committee 1-20-2022 Annual review, no clinical content change
Internal Medical Policy Committee 5-24-2022 Added asparaginase erwinia chrysanthemi (Rylaze), J9021, to the policy, removed NCCN recommendations and added this statement "Pegaspargase (Oncaspar), asparaginase erwinia chrysanthemi (Erwinaze, Rylaze) and calaspargase pegol-mknl (Asparlas) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations."