Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Polatuzumab vedotin-piiq (Polivy) may be considered medically necessary in individuals 18 years of age and older for the following:
Diffuse Large B-Cell Lymphoma (DLBCL)
Compendia Sources
Polatuzumab vedotin (Polivy) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations
The use of polatuzumab vedotin (Polivy) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Code
