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)
-
For the treatment of relapsed or refractory diffuse large B cell lymphoma (DLBCL) when
ALL
of the following criteria are met:
-
Given in combination with bendamustine and a rituximab product;
and
-
Documentation of at least two (2) prior therapies;
or
-
For the treatment of previously untreated DLBCL, not otherwise specified or high-grade B-cell lymphoma (HGBL) when ALL the following criteria are met:
-
Individual has International Prognostic Index score of two (2) or greater;
and
-
Given in combination with a rituximab product, cyclophosphamide, doxorubicin, and prednisone (R-CHP);
or
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
