Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)

Policy ID: I-038-028

Section: Injections

Effective Date: July 01, 2018

Revised Date: September 15, 2021

Revision Effective Date: October 01, 2021

Last Reviewed: September 21, 2021

Description

Rituximab (Rituxan^®) is a genetically engineered chimeric murine/human monoclonal antibody. It binds specifically to the antigen CD20 (human B-lymphocyte-restricted differentiation antigen, Bp35). This antigen is a hydrophobic transmembrane protein that is located on pre-B and mature B lymphocytes. It is also expressed on more than 90 percent of B-cell non-Hodgkin's lymphomas, but it is not expressed on hematopoietic stem cells, pro-B cells, normal plasma cells, or other normal tissues.

Rituximab and hyaluronidase human (Rituxan Hycela) is a combination of rituximab and hyaluronidase human in a subcutaneous formulation that is given by a healthcare professional after an initial administration of intravenous rituximab (Rituxan). These two products are different formulations and cannot be used interchangeably.

Rituximab-abbs (Truxima®), rituximab-arrx (Riabni™), and rituximab-pvvr (Ruxience) are biosimilars of rituximab (Rituxan).

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.

Rituximab (Rituxan)

Food and Drug Administration (FDA) Approved Indications

Rituximab (Rituxan) may be considered medically necessary for ANY of the following indications:

Antineutrophil Cytoplasmic Antibody-Associated Vasculitides (Granulomatosis with Polyangiitis [Wegener Granulomatosis] and Microscopic Polyangiitis)

Treatment of individuals with antineutrophil cytoplasmic antibody-associated vasculitides (i.e., granulomatosis with polyangiitis (GPA) [Wegener granulomatosis] and microscopic polyangiitis), in combination with glucocorticoids; or

Chronic Lymphocytic Leukemia (CLL)

Treatment of previously untreated and previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide (FC); or

Non-Hodgkin's Lymphoma (NHL)

Treatment of NHL in any of the following:

Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent; or
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in individuals achieving a complete or partial response to rituximab (Rituxan) in combination with chemotherapy, as single-agent maintenance therapy; or
Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or
Previously untreated diffuse large B-cell, CD20-positive NHL in combination with (cyclophosphamide, doxorubicin, vincristine, and prednisone) (CHOP) or other anthracycline-based chemotherapy regimens; or

Pemphigus Vulgaris (PV)

Treatment of moderate to severe treatment-refractory PV in individuals 18 years or older; or

Rheumatoid Arthritis (RA)

Treatment of individuals 18 years of age or older with RA who meet the following criteria:
- Individual has had an inadequate response to one (1) or more tumor necrosis factor inhibitors, or is not suitable for treatment with tumor necrosis factor inhibitors; or
- Combination therapy with methotrexate or other conventional synthetic DMARD not applicable to individuals who have had an inadequate response to methotrexate or other conventional synthetic DMARDs.
- RA is moderately to severely active (e.g., greater than or equal to eight (8) swollen and tender joints); and
- Rituximab (Rituxan) is administered in combination with methotrexate, or other conventional synthetic disease-modifying anti-rheumatic drug (DMARD) if methotrexate is contraindicated; and

The use of rituximab (Rituxan) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.

Procedure Codes

J9312

Other clinically supported indications

Rituximab (Rituxan) may be considered medically necessary for ANY of the following off-label indications:

Autoimmune Hemolytic Anemia (AIHA)

Warm AIHA in glucocorticoid-refractory or glucocorticoid-dependent individuals; or
Cold agglutination syndrome; or

Churg-Strauss Syndrome (Eosinophilic Granulomatosis with Polyangiitis)

First-line treatment in combination with glucocorticoids for individuals with severe (organ-threatening) disease; or
Add-on therapy for treatment-refractory disease; or

Epstein-Barr virus disease; Prophylaxis - Hemopoietic stem cell transplant

Prophylaxis for Epstein Barr virus infection in pediatric individuals undergoing hematopoietic stem cell transplant; or

Evans syndrome (Pediatric only)

Treatment for Evans syndrome refractory to immunosuppressive therapy; or

Hemophilia

Treatment of individuals 18 years of age or older for hemophilia with acquired inhibitors in individuals who are refractory to conventional first line treatments (i.e. immunosuppression with prednisone and cyclophosphamide); or

Hepatitis C Virus‒Associated Cryoglobulinemic Vasculitis

As add-on therapy for individuals with hepatitis C virus‒associated cryoglobulinemic vasculitis who have:
- Active disease resistant to antiviral drugs; or
- Severe or life-threatening cryoglobulinemic vasculitis; or

Idiopathic Membranous Nephropathy

As treatment for idiopathic membranous nephropathy; or

Immune thrombocytopenia, previously treated (Pediatric only)

Treatment for pediatric individuals with previously treated primary and secondary immune thrombocytopenia; or

Inflammatory Myopathy (Idiopathic)

Treatment for individuals 18 years of age or older who have failed to respond to, or are intolerant to, another immunosuppressant (e.g. methotrexate) with refractory idiopathic inflammatory myopathy; or

Lupus Nephritis

As add-on therapy for lupus nephritis refractory to standard first-line treatment regimen; or

Microscopic polyarteritis nodosa (Adult only)

Treatment for microscopic polyarteritis nodosa in combination with glucocorticoids; or

Minimal change disease (Pediatric only)

Treatment for remission induction and maintenance of remission in pediatric individuals who have refractory, steroid-dependent or steroid-resistant minimal change disease; or

Multiple Sclerosis (Primary Progressive)

Treatment for individuals 18 years of age or older with primary progressive multiple sclerosis who have gadolinium brain lesions at baseline and have failed treatment with ocrelizumab; or

Multiple Sclerosis (Relapsing Remitting)

Treatment of relapsing remitting multiple sclerosis when the individuals has experienced therapeutic failure, intolerance, or contraindication to two (2) alternative drug therapies indicated for the treatment of multiple sclerosis (e.g. Avonex, Aubagio, Gilenya, etc.); or

Myasthenia Gravis

Treatment for individuals 18 years of age or older with myasthenia gravis refractory to conventional therapy (e.g., azathioprine, corticosteroids, immunosuppressants, plasma exchange, IV immunoglobulin, thymectomy); or

Myopathy, Idiopathic Inflammatory

Treatment for refractory idiopathic inflammatory myopathy in individuals who have failed to respond to, or are intolerant to, another immunosuppressant (e.g. methotrexate); or

Neuromyelitis Optica

Rituximab (Rituxan) may be considered medically necessary as treatment for neuromyelitis optica for relapse prevention; or

Pemphigoid Diseases

Treatment for ANY of the following pemphigoid diseases in treatment-refractory individuals:
- Bullous pemphigoid; or
- Mucous membrane pemphigoid, including ocular cicatricial pemphigoid; or
- Epidermolysis bullosa acquisita; or

Pemphigus Diseases

Treatment for pemphigus diseases (i.e., pemphigus vulgaris, paraneoplastic pemphigus); or

Pemphigus Foliaceus

Treatment for individuals 18 years of age or older with pemphigus foliaceus in combination with a tapering course of corticosteroids; or

Sjogren's Syndrome (Primary)

Treatment for individuals 18 years of age or older with primary Sjogren's syndrome as a one (1) time course of treatment over 15 days; or

Systemic Lupus Erythematosus

Treatment as add-on therapy for systemic lupus erythematosus refractory to immunosuppressive therapy; or

Systemic Sclerosis (Scleroderma)

Treatment for systemic sclerosis (scleroderma) in individuals refractory to first-line treatment; or

Thrombocytopenic purpura (Idiopathic)

Treatment for individuals 18 years of age or older with idiopathic thrombocytopenic purpura refractory to first-line therapy (e.g., corticosteroids, IV immune globulin, splenectomy, etc.) who are at risk of bleeding (grade 2C); or

Thrombotic Thrombocytopenic Purpura

Treatment in combination with steroids and plasma exchange in individuals 18 years of age or older with refractory thrombotic thrombocytopenic purpura (i.e., lack of response to plasma exchange therapy and glucocorticoids).

The use of rituximab for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.

Procedure Codes

J9312

National Comprehensive Cancer Network (NCCN) Approved Recommendations

Rituximab (Rituxan) may be considered medically necessary for ANY of the following indications:

Acute Lymphoblastic Leukemia (ALL)

Induction/consolidation therapy for Philadelphia chromosome-negative ALL in adolescent and young adult (AYA) and adult individuals less than 65 years of age as a component of:
- GRAALL-2005 regimen (daunorubicin, vincristine, prednisone, pegaspargase, and cyclophosphamide) with rituximab for CD20-positive disease (individuals aged less than 60 years); or
- HyperCVAD (hyper-fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone, alternating with high-dose methotrexate and cytarabine), with or without rituximab for CD20-positive disease; or
Induction therapy for Philadelphia chromosome-negative ALL in adults aged greater than or equal to 65 years as a component of GMALL (idarubicin, dexamethasone, vincristine, cyclophosphamide, and cytarabine, with or without rituximab for CD20-positive disease) (moderate intensity); or
Therapy for relapsed/refractory Philadelphia chromosome-negative ALL or for relapsed/refractory Philadelphia chromosome-positive ALL refractory to TKIs as a component of MOpAD regimen (methotrexate, vincristine, pegaspargase, dexamethasone) with rituximab for CD20-positive disease; or
Therapy for relapsed/refractory Philadelphia chromosome-positive ALL as a component of MOpAD regimen (methotrexate, vincristine, pegaspargase, dexamethasone) with rituximab for CD20-positive disease and TKI; or

B-Cell Lymphoma - AIDS-Related

Treatment in combination with growth factor support for AIDS-related Burkitt lymphoma as a component of:
- DA-EPOCH-R (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- Modified CODOX-M (cyclophosphamide, doxorubicin, and vincristine, with intrathecal methotrexate and cytarabine followed by high-dose systemic methotrexate) regimen alternating with IVAC (ifosfamide, cytarabine, etoposide, and intrathecal methotrexate) regimen with rituximab; or
In combination with growth factor support for AIDS-related Burkitt lymphoma as a component of R-HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine) regimen; or
Second-line therapy for relapse of AIDS-related Burkitt lymphoma as a component of:
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab (if not previously given as first-line therapy); or
- RICE (rituximab, ifosfamide, carboplatin, and etoposide) regimen in combination with intrathecal methotrexate (if not previously given); or
- RIVAC (rituximab, ifosfamide, cytarabine, etoposide) regimen in combination with intrathecal methotrexate (if not previously given); or
- RGDP (rituximab, gemcitabine, dexamethasone, cisplatin) regimen; or
- High-dose cytarabine and rituximab regimen; or
Treatment In combination with growth factor support for CD20+ AIDS-related diffuse large B-cell lymphoma (DLBCL) primary effusion lymphoma and HHV8-positive DLBCL, not otherwise specified (NOS) as a component of R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
In combination with growth factor support for CD20+ AIDS-related diffuse large B-cell lymphoma and HHV8-positive DLBCL, not otherwise specified (NOS) as a component of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with rituximab; or
Used for relapsed AIDS-related DLBCL, HHV8-positive DLBCL, not otherwise specified (NOS), and primary effusion lymphoma in combination with bortezomib-ICE (ifosfamide, carboplatin, and etoposide) regimen; or
Second-line therapy or subsequent therapy for relapse of AIDS-related DLBCL, primary effusion lymphoma, and HHV8-positive DLBCL, not otherwise specified (NOS):
- For individuals with intention to proceed to transplant as a component of DHAP (dexamethasone, cisplatin, and cytarabine), DHAX (dexamethasone, cytarabine, and oxaliplatin), ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin), GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin), GemOX (gemcitabine and oxaliplatin), ICE (ifosfamide, carboplatin, and etoposide), or MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen with rituximab; or
- In non-candidates for transplant as a single agent, in combination with polatuzumab vedotin-piiq with or without bendamustine (greater than or equal to two (2) prior therapies), with lenalidomide (for non-germinal center DLBCL) or bendamustine, with gemcitabine and vinorelbine, or as a component of CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine), dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), CEOP (cyclophosphamide, etoposide, vincristine, and prednisone), GDP, or GemOX regimen with rituximab; or

B-Cell Lymphomas - Burkitt Lymphoma

Induction therapy for low-risk disease for individuals less than 60 years of age as a component of:
- CODOX-M (cyclophosphamide, doxorubicin, and vincristine, with intrathecal methotrexate and cytarabine followed by high-dose systemic methotrexate) regimen (original or modified) regimen with rituximab; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate; or
- HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab(regimen includes intrathecal therapy); or
Induction therapy for high-risk disease in individuals less than 60 years of age as a component of:
- CODOX-M (cyclophosphamide, doxorubicin, and vincristine, with intrathecal methotrexate and cytarabine followed by high-dose systemic methotrexate) regimen (original or modified) alternating with IVAC (ifosfamide, cytarabine, etoposide, and intrathecal methotrexate) regimen with rituximab; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate for individuals not able to tolerate aggressive therapy; or
- Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab (regimen includes intrathecal therapy); or
Induction therapy for low-risk and high-risk disease in individuals 60 years of age or older as a component of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate; or
Used as a component of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate, RICE (rituximab, ifosfamide, carboplatin, and etoposide) regimen with intrathecal methotrexate if not previously given, RIVAC (rituximab, ifosfamide, cytarabine, and etoposide) regimen with intrathecal methotrexate if not previously given:
- As second-line therapy for relapse of Burkitt lymphoma greater than 6-18 months following appropriate first-line therapy; or
- For individuals with partial response to second-line therapy as additional therapy (if not previously given) for relapse or refractory disease; or
Second-line therapy for individuals with disease relapse greater than 6-18 months after appropriate first-line therapy or for individuals with partial response to second-line therapy as additional therapy (if not previously given) for relapsed or refractory disease:
- As a component of RGDP (rituximab, gemcitabine, dexamethasone, and cisplatin) regimen; or
- As a component of high-dose cytarabine with rituximab regimen; or

B-Cell Lymphomas - Castleman's Disease (CD)

Used for unicentric CD with or without prednisone and/or cyclophosphamide:
- For surgically unresectable disease; or
- For symptomatic disease following incomplete resection; or
- As second-line therapy for relapsed or refractory disease; or
Therapy for active multicentric CD with no organ failure with or without prednisone for individuals who are human immunodeficiency virus-negative and human herpesvirus-8-negative:
- As primary treatment; or
- For relapsed disease; or
- If no response to primary treatment; or
Therapy for active multicentric CD with no organ failure with or without liposomal doxorubicin and/or prednisone for individuals who are human herpesvirus-8-positive:
- As preferred** primary treatment; or
- For relapsed disease; or
- If no response to primary treatment; or
Used with or without prednisone for active multicentric CD with no organ failure for progression greater than or equal to six (6) months following completion of rituximab; or
Primary treatment for multicentric CD for individuals with fulminant human herpesvirus-8 with or without organ failure:
- In combination with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- In combination with CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) regimen; or
- In combination with CVP (cyclophosphamide, vincristine, and prednisone) regimen; or
- In combination with Liposomal doxorubicin; or
- As a single agent if individual is not a candidate for combination therapy; or
Treatment for refractory or progressive multicentric CD in combination with liposomal doxorubicin or with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone), or CVP (cyclophosphamide, vincristine, and prednisone) regimen:
- As initial treatment; or
- If no response to initial treatment for refractory or progressive disease; or
Subsequent therapy for multicentric CD that has progressed following treatment of relapsed/refractory or progressive disease in combination with:
- Bortezomib; or
- Lenalidomide; or
- Thalidomide; or

B-Cell Lymphomas - Diffuse Large B-Cell Lymphoma (DLBCL)

First-line therapy for stage I-II disease as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
First-line therapy for stage I-II disease for individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
First-line therapy for stage I-II disease for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
First-line therapy for stage III-IV disease as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
First-line therapy for stage III-IV disease in individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen or
First-line therapy for stage III-IV disease for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
Second-line or subsequent therapy for partial response, no response, relapsed, progressive, or refractory disease in individuals with intention to proceed to transplant as a component of:
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen with rituximab; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen with rituximab,
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen with rituximab; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen with rituximab; or
- GemOX (gemcitabine and oxaliplatin) regimen with rituximab; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen with rituximab; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen with rituximab; or
Second-line or subsequent therapy for partial response, no response, relapsed, progressive, or refractory disease in non-candidates for transplant:
- As a single agent; or
- In combination with lenalidomide (non-germinal center lymphoma); or
- In combination with bendamustine; or
- In combination with Polatuzumab vendotin-piiq with or without bendamustine after greater than or equal to two (2) prior therapies; or
- As a component of CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) with rituximab regimen; or
- As a component of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) with rituximab regimen; or
- As a component of CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) with rituximab regimen; or
- As a component of GDP with rituximab regimen; or
- As a component of GemOX with rituximab regimen; or
- As a component of gemcitabine and vinorelbine regimens with rituximab; or
First-line therapy for primary mediastinal large B-cell lymphoma as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- Dose-dense RCHOP regimen followed by ICE (ifosfamide, carboplatin, and etoposide) regimen; or
First-line therapy for grey zone lymphoma as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
First-line therapy for grey zone lymphoma for individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
First-line therapy for grey zone lymphoma for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
Treatment of primary cutaneous DLBCL, leg type as first-line with involved site radiation therapy or as second-line therapy (if not previously received) for solitary regional T 1-2 disease, or as firs-line therapy for generalized cutaneous, T3 disease:
- As a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
Treatment of primary cutaneous DLBCL, leg type as first-line with involved site radiation therapy or as second-line therapy (if not previously received) for solitary regional T 1-2 disease, or as firs-line therapy for generalized cutaneous, T3 disease in individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
Treatment of primary cutaneous DLBCL, leg type as first-line with involved site radiation therapy or as second-line therapy (if not previously received) for solitary regional T 1-2 disease, or as firs-line therapy for generalized cutaneous, T3 disease for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
First-line therapy for extracutaneous primary cutaneous DLBCL, leg type as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
First-line therapy for extracutaneous primary cutaneous DLBCL, leg type for individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
First-line therapy for extracutaneous primary cutaneous DLBCL, leg type for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or

B-Cell Lymphomas -Follicular Lymphoma (grade 1-2)

First-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for individuals with the indications for treatment with stage III or IV disease as:
- A component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- A component of RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- In combination with bendamustine or lenalidomide; or
Used as a single agent in elderly or infirm individuals when tolerability of combination chemotherapy is a concern as:
- First-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for individuals with indications for treatment with stage III or IV disease; or
- Second-line or subsequent therapy (if not previously given as first-line) for refractory or progressive disease in individuals with indications for treatment; or
Used in elderly or infirm individuals with indications for treatment in combination with chlorambucil or in combination with cyclophosphamide as:
- First-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for individuals with indications for treatment with stage III or IV disease; or
- Second-line or subsequent therapy (if not previously given as first-line) for refractory or progressive disease in individuals with indications for treatment; or
First-line therapy for stage I, contiguous stage II non-contiguous stage II disease, or for individuals with indications for treatment with stage III or IV disease as a single agent in individuals that were initially observed and have progressed with a low tumor burden; or
First-line therapy for stage I, II pediatric-type follicular lymphoma in adults with extensive local disease who are not candidates for excision or involved site radiation therapy as a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) regimen; or
Second-line or subsequent therapy for refractory or progressive disease in individuals with indications for treatment as a single agent or in combination with:
- Bendamustine (if not previously given as first-line); or
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen (if not previously given as first-line); or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen ( if not previously given as first-line); or
- Lenalidomide (if not previously given as first line); or
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- Gemcitabine and vinorelbine; or
- Polatuzumab vendotin-piiq with or without bendamustine; or
Treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) and rituximab regimen; or
Treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy and have poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine and prednisolone) regimen; or
Treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy and are very frail and for individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP regimen; or
- RGCVP regimen; or
Used in combination with polatuzumab vedotin-piiq with or without bendamustine as treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy prior to histologic transformation and have no response or progressive disease after chemoimmunotherapy; or
Treatment of histologic transformation to DLBCL with translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy as a component of:
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- R-CODOX-M (rituximab, cyclophosphamide, vincristine, and doxorubicin with methotrexate) regimen alternating with R-IVAC (rituximab, ifosfamide, etoposide, and cytarabine) regimen; or
Treatment of histologic transformation to DLBCL in individuals who have received multiple lines of chemoimmunotherapy for indolent or transformed disease as a single agent or in combination with:
- Bendamustine; or
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- Lenalidomide; or
- Gemcitabine and vinorelbine; or
- Polatuzumab vendotin-piiq with or without bendamustine; or
First-line consolidation therapy in individuals with indications for treatment if initially treated with single-agent rituximab; or
Maintenance therapy:
- As first-line consolidation or extended dosing in individuals initially presenting with high tumor burden (stage III, IV) who achieve a complete or partial response following treatment with RCHOP (rituximab, cyclophosphamide, doxorubicin, and prednisone) regimen or RCVP (rituximab, cyclophosphamide, vincristine and prednisone) regimen; or
- Second-line consolidation or extended dosing; or
- Can be considered for individuals with histologic transformation to DLBCL that is coexisting with extensive follicular lymphoma who achieve a complete response to chemoimmunotherapy; or

B-Cell Lymphomas - Gastric MALT Lymphoma

Initial therapy (if involved site radiation therapy is contraindicated) as a single agent stage I₁, or I₂, or stage II₁disease in individuals who are H-pylori-positive and t(11;18) positive or who are H-pylori-negative; or
Treatment for individuals with indications for treatment as a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen, RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen, or in combination with bendamustine:
- As first-line therapy for stage IIE, or II₂, or stage IV disease (distant nodal, advanced stage); or
- As additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and involved site radiation therapy (ISRT); or
- As additional therapy after ISRT or rituximab alone for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
Used as a single agent in individuals with indications for treatment as:
- First-line therapy for stage IIE, or II₂, or stage IV (distant nodal or advanced stage); or
- Additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and ISRT; or
- Additional therapy after involved site radiation therapy ISRT alone for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
- second-line or subsequent therapy for recurrent or progressive disease (if longer duration of remission); or
Used in combination with lenalidomide for individuals with indications for treatment as:
- First-line therapy for stage IIE, or II₂, or stage IV disease (distant nodal or advanced stage); or
- Additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and ISRT; or
- Additional therapy after ISRT or rituximab alone) for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
Used as a single agent or in combination with chlorambucil or cyclophosphamide in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy for stage IIE, or II₂, or stage IV (distant nodal or advanced stage) disease; or
- Additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and ISRT; or
- Additional therapy after ISRT or rituximab alone for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
- Second-line or subsequent therapy for recurrent or progressive disease; or
Consolidation as optional first-line extended therapy in individuals initially treated with single agent rituximab; or
Second-line therapy or subsequent therapy for recurrent or progressive disease in individuals with indications for treatment:
- In combination with Bendamustine (not recommended if previously treated with bendamustine**); or
- As a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- As a component of RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- In combination with Lenalidomide (including for the elderly or infirm when tolerability of combination chemotherapy is a concern); or

B-Cell Lymphomas - High-Grade B-Cell Lymphomas

Used as induction therapy for high-grade B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma) or high-grade B-cell lymphomas, not otherwise specified as a component of:
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- R-CODOX-M (rituximab, cyclophosphamide, vincristine, and doxorubicin with methotrexate) regimen alternating with R-IVAC (rituximab, ifosfamide, etoposide, and cytarabine) regimen; or
Used as induction therapy for high-grade B-cell lymphomas, not otherwise specified* as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- R-CODOX-M (rituximab, cyclophosphamide, vincristine, and doxorubicin with methotrexate) regimen alternating with R-IVAC (rituximab, ifosfamide, etoposide, and cytarabine) regimen; or
Second-line or subsequent therapy for partial response, no response, relapsed, progressive, or refractory high-grade B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (Double/Triple Hit Lymphoma) in:
- Individuals with intention to proceed to transplant as a component of DHAP (dexamethasone, cisplatin, and cytarabine), DHAX (dexamethasone, cytarabine, and oxaliplatin), ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin), GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin), GemOX (gemcitabine and oxaliplatin), ICE (ifosfamide, carboplatin, and etoposide), or MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen with rituximab; or
- Non-candidates for transplant as a single agent, in combination with lenalidomide (non-germinal center lymphoma) or bendamustine, or as a component of CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine), dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), CEOP (cyclophosphamide, etoposide, vincristine, and prednisone), GDP, GemOX, or gemcitabine and vinorelbine regimen with rituximab; or
- Non-candidates for transplant in combination with polatuzumab vendotin-piiq with or without bendamustine after greater than or equal to two (2) prior therapies; or
Second-line and subsequent therapy for partial response, no response, relapsed, progressive, or refractory high-grade B-cell lymphoma, NOS, in:
- Individuals with intention to proceed to transplant as component of DHAP, DHAX, ESHAP, GDP, gemcitabine, dexamethasone, and carboplatin, GemOx, ICE, or MINE, regimen with rituximab; or
- Non-candidates for transplant as a single agent, in combination with lenalidomide (non-germinal center lymphoma) or bendamustine, or as a coponet of CEPP, dose-adjusted EPOCH, CEOP, GDP, gemcitabine, dexamethasone, and carboplatin, GemOx, or gemcitabine and vinorelbine regimen with rituximab; or
- Non-candidates for transplant in combination with polatuzumab vevedotin-piiq with or without bendamustine; or

*RCHOP has been associated with inferior outcomes for individuals with highgrade B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma)

B-Cell Lymphomas - Nongastric MALT Lymphoma (Noncutaneous)

First-line therapy for stage I-II disease in selected cases; or
First-line therapy for stage IV disease or recurrent stage I-II disease in individuals with indications for treatment as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- Bendamustine with rituximab; or
First-line therapy as a single agent or in combination with lenalidomide for stage IV disease or recurrent stage I-II disease in individuals with indications for treatment; or
Used as a single agent or in combination with chlorambucil or cyclophosphamide for stage IV disease or recurrent stage I-II disease in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy; or
- Second-line or subsequent therapy for recurrent or progressive disease; or
Second-line or subsequent therapy for recurrent or progressive disease in individuals with indications for treatment in:
- Bendamustine with rituximab; or
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- Lenalidomide with rituximab (including for the elderly or infirm when tolerability of combination chemotherapy is a concern); or
Consolidation as optional first-line extended therapy; or
Second-line or subsequent therapy as a single agent for recurrent or progressive disease in individuals with indications for treatment (if longer duration of remission); or

B-Cell Lymphomas - Nodal Marginal Zone Lymphoma

Used as a single agent or in combination with chlorambucil or cyclophosphamide for stage I, contiguous stage II, non-contiguous stage II, or stage III, IV disease in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy; or
- Second-line or subsequent therapy; or
First-line therapy for stage I, contiguous stage II, non-contiguous stage II, or stage III, or IV disease in individuals with indications for treatment in combination with bendamustine or as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
First-line therapy as a single agent or in combination with lenalidomide for stage I, contiguous stage II, non-contiguous stage II, or stage III, IV disease in individuals with indications for treatment; or
Second-line or subsequent therapy for refractory or progressive disease in individuals with indications for treatment:
- In combination with bendamustine (not recommended if previously treated with bendamustine); or
- In combination with lenalidomide including for the elderly or infirm when tolerability of combination chemotherapy is a concern; or
- As a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- As a component of RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
Consolidation as optional first-line extended therapy; or
Second-line or subsequent therapy as a single agent for refractory or progressive disease in individuals with indications for treatment (if longer duration of remission); or

B-Cell Lymphomas - Histologic Transformation of Marginal Zone Lymphoma to Diffuse Large B-Cell Lymphoma (DLBCL)

Treatment of individuals who have received minimal or no prior chemotherapy as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) and rituximab regimen; or
Treatment of individuals who have received minimal or no prior chemotherapy and have poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine and prednisolone) regimen; or
Treatment of individuals who have received minimal or no prior chemotherapy and are very frail and for individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP regimen; or
- RGCVP regimen; or
Subsequent therapy for individuals who have received multiple lines of chemoimmunotherapy for indolent or transformed disease as a single agent, in combination with bendamustine, or as a component of:
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen with rituximab; or
- Lenalidomide; or
- Gemcitabine and vinorelbine; or
Used in combination with polatuzumab vedotin-piiq with or without bendamustine for individuals who have received multiple prior therapies including greater than or equal to two (2) lines of chemoimmunotherapy for indolent or transformed disease; or

B-Cell Lymphomas - Mantle Cell Lymphoma

Aggressive induction therapy for stage I-II disease that had a partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV TP53 mutation negative (Aggressive induction therapy followed by HDT/ASCR may not be appropriate for TP53 positive disease. ) disease in individuals who are candidates for high-dose therapy/autologous stem cell rescue (HDT/ASCR) as a component of:
- RDHA + platinum (rituximab, dexamethasone, cytarabine) + carboplatin, cisplatin, or oxaliplatin regimen; or
- Alternating RCHOP/RDHAP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)/(rituximab, dexamethasone, cytarabine, and cisplatin) regimen; or
- HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- Bendamustine with rituximab followed by rituximab in combination with high-dose cytarabine; or
Aggressive induction therapy in combination with bendamustine for stage I-II disease that had a partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV TP53 mutation negative disease (Aggressive induction therapy followed by HDT/ASCR may not be appropriate for TP53 positive disease.); or
Less aggressive induction therapy for stage I-II disease as initial therapy (localized presentation, extremely rare), or for partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV TP53 mutation positive disease in individuals who are not candidates for high dose therapy/autologous stem cell rescue in combination with bendamustine or lenalidomide, or as a component of
- VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) regimen; or
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with rituximab; or
Less aggressive induction therapy for stage I-II disease (localized presentation, extremely rare) as initial therapy, or for partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV TP53 mutation positive disease, or symptomatic indolent stage II bulky, III, or IV disease in individuals who are not candidates for high-dose therapy/autologous stem cell rescue as a component of:
- RBAC500 (rituximab, bendamustine, and cytarabine) regimen; or
- Modified HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab regimen in individuals older than 65 years
Single-agent maintenance therapy for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV disease following complete or very good partial response to less aggressive induction therapy or high-dose therapy with autologous stem cell rescue; or
Second-line therapy for stage I-II disease or aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV disease in individuals who have stable disease or partial response with substantial disease after induction therapy, or who have relapsed or progressed following prior treatment with chemoimmunotherapy:
- In combination with bendamustine (if not previously given); or
- As a component of RBAC500 (rituximab, bendamustine and cytarabine) regimen (f not previously given); or
- In combination with bortezomib; or
- As a component of DHAP (dexamethasone, cisplatin, and cytarabine) with rituximab regimen; or
- As a component of DHAOx (dexamethasone, cytarabine, and oxaliplatin) with rituximab regimen; or
- As a component of GemOx (gemcitabine, oxaliplatin) with rituximab regimen; or
- In combination with ibrutinib and lenalidomide; or
- In combination with venetoclax; or
Second-line or subsequent therapy for stage I-II, aggressive stage II bulky, III, or IV , or symptomatic indolent stage II bulky, III, or IV disease in individuals who have stable disease or partial response with substantial disease after induction therapy, or who have relapsed or progressed following prior chemoimmunotherapy:
- In combination with ibrutinib; or
- In combination with lenalidomide; or

B-Cell Lymphomas - Pediatric Aggressive Mature B-Cell Lymphomas

Induction therapy for individuals with greater than or equal to 20 percent reduction after COP reduction phase as a component of COG ANHL1131 regimen B/induction one (1) and two (2) with COPADM (cyclophosphamide, vincristine, prednisone, doxorubicin, methotrexate, and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen:
- For group B individuals with low-risk disease [stage I or II individuals who are not fully resected or any stage III individual with LDH less than or equal to 2 times the upper limit of normal (ULN)]; or
- For group B individuals with high-risk disease (any stage III individual with LDH greater than two (2) times upper limit of normal (ULN), and all non-CNS stage IV individuals with less than 25 percent bone marrow involvement); or
Consolidation therapy one (1) for individuals with greater than or equal to 20 percent reduction after COP reduction phase as a component of COG ANHL1131 regimen B with CYM (cytarabine, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) with rituximab regimen:
- For group B individuals with low-risk disease [stage I or II individuals who are not fully resected or any stage III individual with LDH less than or equal to two (2) times the ULN]; or
- For group B individuals with high-risk disease (any stage III individual with LDH greater than two (2) times ULN, and all non-CNS stage IV individuals with less than 25 percent bone marrow involvement); or
Induction therapy as a component of COG ANHL1131 regimen C1/induction one (1) and two (2) with R-COPADM (cyclophosphamide, vincristine, prednisone, doxorubicin, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) with rituximab regimen for:
- Group B individuals with less than 20 percent size reduction after COP reduction phase; or
- Group C individuals with CNS negative disease after initial treatment with COP reduction phase; or
- Group C individuals with CNS positive and CSF negative or positive disease after initial treatment with COP reduction phase; or
Alternative induction therapy as a component of COG ANHL1131 regimen C3*/induction one (1) and two (2) with R-COPADM (cyclophosphamide, vincristine, prednisone, doxorubicin, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) with rituximab regimen for:
- Group C individuals with CNS and CSF positive disease; or
- Group C individuals on regimen C1 therapy with less than 20 percent size reduction after COP reduction phase; or
Consolidation therapy one (1) and two (2) as a component of COG ANHL1131 regimen C1 with R-CYVE (cytarabine, etoposide and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen:
- For group B individuals with less than complete response after first cycle of consolidation with CYM (cytarabine, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) regimen; or
- For group C individuals with CNS negative disease; or
- For group C individuals with CNS positive disease, plus high-dose methotrexate and additional intrathecal therapy with methotrexate, cytarabine, and hydrocortisone after R-CYVE 1 only; or
Consolidation therapy one (1) and two (2) as a component of COG ANHL1131 regimen C3 with R-CYVE (cytarabine, etoposide and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen for group C individuals with CNS and CSF positive disease, plus high-dose methotrexate and additional intrathecal therapy with methotrexate, cytarabine, and hydrocortisone after R-CYVE one (1) only; or
Preferred treatment for relapsed or refractory disease (if not previously received as a part of initial therapy) as a component of R-CYVE (cytarabine, etoposide, and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen; or
Preferred treatment for relapsed or refractory disease as a component of R-ICE (ifosfamide, carboplatin, and etoposide) with rituximab regimen; or

B-Cell Lymphomas - Post-transplant Lymphoproliferative Disorder (PTLD)

Single-agent therapy as:
- First-line therapy for monomorphic (B-cell type) or polymorphic (B-cell type) PTLD; or
- Second-line therapy for partial response, persistent or progressive non-destructive lesions or for partial response, persistent or progressive monomorphic (B-cell type) PTLD if immunosuppressive was reduced in first-line therapy; or
- Maintenance therapy for polymorphic (B-cell type) PTLD achieving complete response on first-line therapy; or
Concurrent chemoimmunotherapy for CD20+ disease as a component of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with rituximab or as a component of CVP (cyclophosphamide, vincristine, and prednisone), CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine), or CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen with rituximab for frail individuals who cannot tolerate anthracyclines as:
- First-line therapy for monomorphic (B-cell type) or systemic polymorphic (B-cell type) PTLD; or
- Second-line therapy for partial response, persistent or progressive monomorphic (B-cell type) or polymorphic (B-cell type) PTLD; or
Sequential chemoimmunotherapy as a single agent followed by CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with or without rituximab as:
- First-line therapy for monomorphic (B-cell type) or systemic polymorphic (B-cell type) PTLD; or
- Second-line therapy for persistent or progressive monomorphic (B-cell type) or polymorphic (B-cell type) PTLD; or
Used in combination with high-dose methotrexate for primary CNS PTLD (B-cell type); or
Second-line and subsequent therapy for individuals with partial response, persistent or progressive disease after receiving chemoimmunotherapy as first-line treatment for monomorphic PTLD (B-cell type) as a single agent or in combination with:
- Bendamustine; or
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen with rituximab; or
- Lenalidomide; or
- Gemcitabine and vinorelbine; or
- Polatuzumab vedotin-piiq with or without bendamustine (after greater than or equal to two (2) prior therapies; or

B-Cell Lymphoma - Primary Cutaneous

Therapy for primary cutaneous marginal zone or follicle center lymphoma with:
- Solitary/regional, T1-2 disease that is refractory to initial therapy; or
- Generalized disease (skin only), T3 disease; or

Central nervous system cancers - Leptomeningeal metastases

Intra-cerebrospinal fluid (CSF) treatment for leptomeningeal metastases from lymphomas for:
- Primary treatment in individuals with good risk status (KPS greater than or equal to 60, no major neurologic deficits, minimal systemic disease, and reasonable systemic treatment options if needed); or
- Maintenance treatment in individuals with negative CSF cytology or in clinically stable individuals with persistently positive CSF cytology; or
- Treatment in individuals with positive CSF cytology that have progressed after receiving prior treatment; or

Central Nervous System Cancers - Primary CNS Lymphoma:

Induction therapy:
- In combination with high-dose methotrexate; or
- In combination with high-dose methotrexate and temozolomide; or
- As a component of R-MPV (rituximab, methotrexate, procarbazine, and vincristine) regimen; or
- In combination with high-dose methotrexate and temozolomide followed by post-RT temozolomide; or
- As a single agent if individual is unsuitable for or intolerant to high-dose methotrexate; or
- In combination with temozolomide if individual is unsuitable for or intolerant to high-dose methotrexate; or
- In combination with lenalidomide if individual is unsuitable for or intolerant to high-dose methotrexate; or
Consider as intra-CSF therapy if CSF positive or spinal MRI positive as:
- Part of induction therapy; or
- Treatment alone or in combination with systemic chemotherapy for relapsed or refractory disease in individuals with prior WBRT; or
Consider for consolidation therapy as continuation of induction regimen in individuals with complete response or complete response unconfirmed (CRu) to induction therapy:
- In combination with high-dose methotrexate; or
- In combination with high-dose methotrexate and temozolomide; or
- As a component of R-MPV (rituximab, methotrexate, procarbazine, and vincristine) regimen; or
- In combination with high-dose methotrexate and temozolomide followed by post-RT temozolomide; or
Treatment as a single agent or in combination with temozolomide or lenalidomide for relapsed or refractory disease:
- May be considered in individuals who received prior whole brain radiation therapy (RT); or
- In individuals who received a prior high-dose methotrexate-based regimen without prior RT; or
- In combination with whole brain RT or involved field RT in individuals who received a prior high-dose methotrexate-based regimen without prior RT after no response or short response duration (less than 12 months) to prior regimen; or
- In individuals who received prior high-dose chemotherapy with stem cell rescue; or
Treatment in combination with high-dose methotrexate with or without ibrutinib for relapsed or refractory disease:
- In individuals who received prior whole brain radiation; or
- In individuals who received a prior high-dose methotrexate-based regimen without prior radiation therapy (RT) and a previous long response duration (greater than or equal to 12 months) to prior regimen; or

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

First-line therapy for disease without del(17p)/TP53 mutation in frail individuals with significant comorbidity (not able to tolerate purine analogs) or in individuals age greater than or equal 65 years and younger individuals with significant comorbidities (CrCl less than 70 ml/min) who have indications for treatment:
- In combination with high-dose methylprednisolone; or
- As a single agent; or
First-line therapy in combination with bendamustine for disease without del(17p)/TP53 mutation in individuals greater than or equal to 65 years of age and younger individuals with or without significant comorbidities who have indications for treatment (not recommended for frail individuals) ; or
First-line therapy for disease without del(17p)/TP53 mutation in individuals age less than 65 years without significant comorbidities who have indications for treatment:
- In combination with ibrutinib; or
- In combination with high-dose methylprednisolone; or
- As a component of PCR (pentostatin, cyclophosphamide, and rituximab) regimen; or
First-line therapy for disease with del(17p)/TP53 mutation in combination with alemtuzumab or high-dose methylprednisolone in individuals with indications for treatment; or
First line therapy for disease without del(17p)/TP53 mutations in individuals less than 65 years of age without significant comorbidities who have indications for treatment as a component of:
- FCR (fludarabine, cyclophosphamide, and rituximab) regimen (for individuals with IGHV mutated CLL); or
- Fludarabine and rituximab (FR) regimen [not recommended for CLL with del(11q)]; or
Second-line and subsequent therapy for CLL/SLL without del(17p)/TP53 mutation in frail individuals with significant comorbidity or age greater than or equal to 65 years and younger individuals with significant comorbidities (creatining clearance less than 70 mL/min) who have indications for retreatment:
- In combination with idelalisib or venetoclax; or
- As a single agent in a dose-dense regimen; or
- In combination with alemtuzumab, chlorambucil. lenalidomide, or high-dose methylprednisolone; or
- As a component of reduced-dose FCR (fludarabine, cyclophosphamide, and rituximab) or reduced-dose PCR (pentostatin, cyclophosphamide, and rituximab) regimen; or
Second-line and subsequent therapy in combination with bendamustine and with or without ibrutinib or idelalisib for CLL/SLL without del(17p)/TP53 mutation in individuals greater than or equal to 65 years of age or younger individuals with significant comorbidities (CrCl less than 70 ml/min) who have indications for retreatment (not recommended for frail individuals); or
Second-line and subsequent therapy for CLL/SLL without del(17p)/TP53 mutation in individuals less than 65 years without significant comorbidities who have indications for retreatment:
- In combination with idelalisib or venetoclax; or
- In combination with alemtuzumab, bendamustine with or without ibrutinib or idelalisib, high-dose methylprednisolone, or lenalidomide; or
- As a component of FCR (fludarabine, cyclophosphamide, and rituximab) or PCR (pentostatin, cyclophosphamide, and rituximab) regimen; or
Second-line and subsequent therapy for CLL/SLL with del(17p)/TP53 in individuals with indications for retreatment in combination with:
- Idelalisib or venetoclax; or
- Alemtuzumab, lenalidomide, or high-dose methylprednisolone; or
Initial therapy for histologic (Richter's) transformation to DLBCL (clonally related or unknown clonal status) as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) with rituximab regimen; or
- HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab regimen alternating with high-dose methotrexate and cytarabine regimen; or
- OFAR (oxaliplatin, fludarabine, cytarabine, and rituximab) regimen; or

Hairy Cell Leukemia

Used in individuals with indications for treatment in combination with:
- Cladribine as initial therapy; or
- Cladribine for less than complete response or relapse within two (2) years of complete response following initial treatment with pentostatin; or
- Pentostatin for less than complete response or relapse within two (2) years of complete response following initial treatment with cladribine; or
- Cladribine or pentostatin for relapse greater than or equal to two (2) years following initial treatment; or
- Vemurafenib for progression after therapy for relapsed/refractory disease; or
As a single agent in individuals with indications for treatment who are unable to receive purine analogs for:
- Less than complete response following initial treatment with cladribine or pentostatin; or
- Relapse; or

Hematopoietic Cell Transplantation

For chronic graft-versus-host disease (GVHD) as additional therapy in conjunction with systemic corticosteroids following no response (steroid refractory disease) to first-line therapy options; or

Hodgkin Lymphoma - Nodular Lymphocyte-Predominant

Primary treatment as a component of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) + rituximab, CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + rituximab, or CVP (cyclophosphamide, vinblastine, prednisolone) + rituximab for individuals 18 years of age or older:
- With involved site radiation therapy (ISRT) for stage IA or IIA disease (bulky or non-contiguous); or
- With ISRT for stage IB or IIB disease; or
- With or without ISRT for stage III-IV disease; or

Primary treatment as a single agent for stage III or IV disease; or
Second-line or subsequent systemic therapy (if not previously used) for progressive, relapsed, or refractory disease as a single agent, with or without ISRT; or
May be considered as maintenance therapy for individuals treated with second-line systemic therapy with rituximab alone for progressive, relapsed, or refractory disease; or
Second-line or subsequent systemic therapy (if not previously used) for progressive, relapsed, or refractory disease in combination with:
- DHAP (dexamethasone, cisplatin, and high-dose cytarabine); or
- ESHAP (etoposide, methylprednisolone, high-dose cytarabine, and cisplatin); or
- ICE (ifosfamide, carboplatin, and etoposide); or
- IGEV (ifosfamide, gemcitabine, and vinorelbine); or
- Bendamustine; or
- ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) + rituximab; or
- CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + rituximab; or
- CVP (cyclophosphamide, vinblastine, prednisolone) + rituximab; or

Immune Checkpoint Inhibitor-Related Toxicities

Management of the following immunotherapy-related toxicities:
- As additional therapy for moderate (G2), severe (G3) or life-threatening (G4) immunotherapy-related bullous dermatitis; or
- Moderate, severe, or life-threatening steroid-refractory myalgias or myositis; or
- For severe (G 3-4) myasthenia gravis in individuals refractory to plasmapheresis or intravenous immune globulin (IVIG)
- Treatment of immunotherapy-related encephalitis after viral causes have been excluded in individuals positive for autoimmune encephalopathy antibody, or who have had limited or no improvement after seven (7)-14 days on pulse-dose methylprednisolone with or without IVIG; or

Rosai-Dorfman Disease

First-line or subsequent therapy, irrespective of mutation for nodal and immune-cytopenia diseases, as a single agent for:
- Symptomatic unresectable (bulky/site of disease) unifocal disease; or
- Symptomatic multifocal disease; or
- Relapsed/refractory disease; or
- Immunoglobulin G4 (IgG4) disease; or

Splenic Marginal Zone Lymphoma

Therapy as a single-agent for symptomatic individuals with splenomegaly who are:
- Hepatitis C negative; or
- Hepatitis C positive with contraindications for hepatitis treatment; or
- Hepatitis C positive with no response to appropriate hepatitis treatment; or
Used as a single agent or in combination with chlorambucil or cyclophosphamide for disease recurrence following initial management of splenomegaly in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy (if treatment naive); or
- Second-line or subsequent therapy; or
First-line therapy for disease recurrence following initial management of splenomegaly in treatment naive individuals with indications for treatment as a single agent, in combination with bendamustine, or as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
Used in combination with lenalidomide as first-line therapy for disease recurrence following initial treatment for splenomegaly in treatment naive individuals with indications for treatment; or
Consolidation as optional first-line extended therapy in individuals initially treated with single agent rituximab; or
Second-line (if prior treatment with rituximab) or subsequent therapy for disease recurrence in individuals with indications for treatment in combination with bendamustine (not recommended if previously treated with bendamustine**) , or as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
Second-line (if previously treated with rituximab) or subsequent therapy in combination with lenalidomide for disease recurrence in individuals with indications for treatment, including the elderly or infirm when tolerability of combination chemotherapy is a concern; or
Second-line or subsequent therapy as a single agent for disease recurrence in individuals with indications for treatment (if previously treated with rituximab with a longer duration of remission); or

Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma

Used as a component of CaRD (carfilzomib, rituximab, and dexamethasone) regimen or in combination with ixazomib and dexamethasone:
- As primary therapy; or
- For relapse if previously used as primary therapy that was well tolerated and elicited a prolonged response; or
Used as primary therapy, for relapse if previously used as primary therapy that was well tolerated and elicited a prolonged response, or for progressive or relapsed disease:
- In combination with bendamustine; or
- In combination with bortezomib and dexamethasone; or
- In combination with ibrutinib; or
- In combination with cyclophosphamide and dexamethasone; or
- As a single agent; or
- In combination with bortezomib; or
- In combination with cyclophosphamide and prednisone; or
- As a component of CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) regimen; or
- In combination with cladribine or fludarabine in individuals who are not potential autologous stem cell transplant candidates; or
- As a component of FCR (fludarabine, cyclophosphamide, and rituximab) regimen in individuals who are not potential autologous stem cell transplant candidates; or
Consider for maintenance therapy following a complete, very good partial, partial, or minor response to primary therapy if regimen included rituximab.

Procedure Codes

J9312

Rituximab and hyaluronidase human (Rituxan Hycela^(R)) subcutaneous (SC) - healthcare administered

FDA Approved Indications

Rituximab and hyaluronidase human (Rituxan Hycela) may be considered medically necessary for adult individuals 18 years of age and older only after individual has received at least one full dose of a rituximab product by intravenous infusion for ANY of the following indications:

Chronic lymphoid leukemia (CLL)

Previously untreated and previously treated CLL in combination with fludarabine and cyclophosphamide (FC); or

Diffuse Large B-Cell Lymphoma (DLBCL)

Previously untreated DLBCL in combination with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or other anthracycline-based chemotherapy regimens; or

Follicular lymphoma (FL)

Relapsed or refractory, follicular lymphoma as a single agent; or
Previously untreated follicular lymphoma in combination with first line chemotherapy and, in individuals achieving a complete or partial response to rituximab (Rituxan) in combination with chemotherapy, as single-agent maintenance therapy; or
Non-progressing (including stable disease), follicular lymphoma as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or

NCCN Approved Recommendations

As a substitute for rituximab (Rituxan) as a single agent or in combination with other systemic therapies (except ibritumomab tiuxetan where indicated for the disease) after individuals have received the first full dose of rituximab by intravenous infusion for the treatment of ANY of the following where rituximab (Rituxan) was recommended for individuals 18 years of age and older:

Castleman's Disease; or
DLBCL; or
Follicular Lymphoma (grade 1-2); or
Gastric MALT; or
High-Grade B-Cell Lymphomas; or
Histologic Transformation of Nodal Marginal Zone Lymphoma to DLBCL; or
High-Grade B-Cell Lymphomas with Translocations of MYC and BCL2 and/or BCL6 (Double/Triple Hit Lymphoma; or
Mantle Cell Lymphoma; or
Nodal Marginal Zone Lymphoma; or
Nongastric MALT Lymphoma (Noncutaneous); or
Post-Transplant Lymphoproliferative Disorders; or
Splenic Marginal Zone Lymphoma; or
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma; or
Hairy Cell Leukemia; or
Primary Cutaneous B-Cell Lymphomas or follicle center lymphoma with:
- Solitary/regional, T1-2 disease that is refractory to initial therapy; or
- Generalized disease (skin only), T3; or
Waldenström Macroglobulinemia / Lymphoplasmacytic Lymphoma.

Individuals receiving rituximab and hyaluronidase human (Rituxan Hycela) cannot have a live vaccination prior to or during treatment with rituximab and hyaluronidase human (Rituxan Hycela).

The use of rituximab and hyaluronidase human (Rituxan Hycela) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.

Procedure Codes

J9311

Rituximab-abbs (Truxima) may be considered medically necessary for the treatment of individuals 18 years and older for ANY of the following indications:

FDA Indications

Chronic Lymphocytic Leukemia (CLL)

For previously untreated or previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide; or

Granulomatosis with Polyangitis, Wegener's Granulomatosis, and Microscopic Polyangiitis

As therapy in combination with glucocorticoids; or

Non-Hodgkin's Lymphoma (NHL)

Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent; or
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in individuals achieving a complete or partial response to a rituximab product in combination with chemotherapy, as a single agent maintenance therapy; or
Non-progressive (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or
Previously untreated DLBCL, CD20-positive NHL in combination with CHOP or anthracycline-based chemotherapy regimens; or

Rheumatoid Arthritis (RA)

As therapy in combination with methotrexate, or other conventional synthetic DMARD if methotrexate is contraindicated, for moderately-to-severely-active RA who have had an inadequate response to one or more TNF antagonist therapies:
- Combination therapy with methotrexate or other conventional synthetic DMARD not applicable to individuals who have had an inadequate response to methotrexate or other conventional synthetic DMARDs; or

NCCN Recommendations

As a substitute for rituximab (Rituxan) for the treatment of ANY of the following where rituximab (Rituxan) was recommended:

Acute Lymphoblastic Leukemia (ALL); or
AIDS-related B-cell lymphoma; or
Burkitt lymphoma; or
Castleman's disease; or
Central Nervous System Cancers - Leptomeningeal metastases; or
Central Nervous System Cancers - Primary CNS Lymphoma; or
Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); or
DLBCL; or
Follicular lymphoma (grade 1-2); or
Gastric MALT lymphoma; or
Hairy cell leukemia; or
Hematopoietic Cell Transplantation; or
High-grade B-cell lymphomas; or
High-grade-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma); or
Histologic transformation of nodal marginal zone lymphoma to DLBCL; or
Mantle cell lymphoma; or
Management of immunotherapy-related toxicities-immune checkpoint inhibitor-related toxicities; or
Nodal marginal zone lymphoma; or
Nongastric MALT lymphoma (noncutaneous); or
Post-transplant lymphoproliferative disorders; or
Primary cutaneous B-cell lymphoma; or
Rosai-Dorfman disease; or
Splenic marginal zone lymphoma; or
Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma

The use of rituximab-abbs (Truxima) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.

Procedure Codes

Q5115

Rituximab-pvvr (Ruxience) or rituximab-arrx (Riabni) may be considered medically necessary for the treatment of individuals 18 years and older for ANY of the following indications:

FDA Indications

Chronic Lymphocytic Leukemia (CLL)

For previously untreated or previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide; or

Granulomatosis with Polyangitis, Wegener's Granulomatosis, and Microscopic Polyangiitis

As therapy in combination with glucocorticoids; or

Non-Hodgkin's Lymphoma (NHL)

Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent; or
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in individuals achieving a complete or partial response to a rituximab product in combination with chemotherapy, as a single agent maintenance therapy; or
Non-progressive (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or
Previously untreated DLBCL, CD20-positive NHL in combination with CHOP or anthracycline-based chemotherapy regimens; or

NCCN Recommendations

As a substitute for rituximab (Rituxan) for the treatment of ANY of the following where rituximab (Rituxan) was recommended:

Acute Lymphoblastic Leukemia (ALL); or
AIDS-related B-cell lymphoma; or
Burkitt lymphoma; or
Castleman's disease; or
Central Nervous System Cancers - Leptomeningeal metastases; or
Central Nervous System Cancers - Primary CNS Lymphoma; or
Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); or
DLBCL; or
Follicular lymphoma (grade 1-2); or
Gastric MALT lymphoma; or
Hairy cell leukemia; or
Hematopoietic Cell Transplantation; or
High-grade B-cell lymphomas; or
High-grade-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma); or
Histologic transformation of nodal marginal zone lymphoma to DLBCL; or
Hodgkin Lymphoma - Nodular Lymphocyte-Predominant; or
Mantle cell lymphoma; or
Management of immunotherapy-related toxicities-immune checkpoint inhibitor-related toxicities; or
Nodal marginal zone lymphoma; or
Nongastric MALT lymphoma (noncutaneous); or
Post-transplant lymphoproliferative disorders; or
Primary cutaneous B-cell lymphoma; or
Rosai-Dorfman disease; or
Splenic marginal zone lymphoma; or
Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma

The use of rituximab-pvvr (Ruxience) or rituximab-arrx (Riabni) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.

Procedure Codes

Q5119

Q5123

*Maintenance rituximab is not appropriate after bendamustine and rituximab therapy and has not been tested after VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) or RBAC (rituximab, bendamustine and cytarabine) therapy.

**Note: Language derived from National Comprehensive Cancer Network (NCCN) guidelines

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J9312

C79.32	C79.63	C81.00	C81.01	C81.02	C81.03	C81.04
C81.05	C81.06	C81.07	C81.08	C81.09	C82.00	C82.01
C82.02	C82.03	C82.04	C82.05	C82.06	C82.07	C82.08
C82.09	C82.10	C82.11	C82.12	C82.13	C82.14	C82.15
C82.16	C82.17	C82.18	C82.19	C82.20	C82.21	C82.22
C82.23	C82.24	C82.25	C82.26	C82.27	C82.28	C82.29
C82.30	C82.31	C82.32	C82.33	C82.34	C82.35	C82.36
C82.37	C82.38	C82.39	C82.40	C82.41	C82.42	C82.43
C82.44	C82.45	C82.46	C82.47	C82.48	C82.49	C82.50
C82.51	C82.52	C82.53	C82.54	C82.55	C82.56	C82.57
C82.58	C82.59	C82.60	C82.61	C82.62	C82.63	C82.64
C82.65	C82.66	C82.67	C82.68	C82.69	C82.80	C82.81
C82.82	C82.83	C82.84	C82.85	C82.86	C82.87	C82.88
C82.89	C82.90	C82.91	C82.92	C82.93	C82.94	C82.95
C82.96	C82.97	C82.98	C82.99	C83.00	C83.01	C83.02
C83.03	C83.04	C83.05	C83.06	C83.07	C83.08	C83.09
C83.10	C83.11	C83.12	C83.13	C83.14	C83.15	C83.16
C83.17	C83.18	C83.19	C83.30	C83.31	C83.32	C83.33
C83.34	C83.35	C83.36	C83.37	C83.38	C83.39	C83.50
C83.51	C83.52	C83.53	C83.54	C83.55	C83.56	C83.57
C83.58	C83.59	C83.70	C83.71	C83.72	C83.73	C83.74
C83.75	C83.76	C83.77	C83.78	C83.79	C83.80	C83.81
C83.82	C83.83	C83.84	C83.85	C83.86	C83.87	C83.88
C83.89	C83.90	C83.91	C83.92	C83.93	C83.94	C83.95
C83.96	C83.97	C83.98	C83.99	C85.10	C85.11	C85.12
C85.13	C85.14	C85.15	C85.16	C85.17	C85.18	C85.19
C85.20	C85.21	C85.22	C85.23	C85.24	C85.25	C85.26
C85.27	C85.28	C85.29	C85.80	C85.81	C85.82	C85.83
C85.84	C85.85	C85.86	C85.87	C85.88	C85.89	C88.0
C88.4	C91.00	C91.01	C91.02	C91.10	C91.12	C91.40
C91.42	D36.0	D47.Z1	D47.Z2	D59.0	D59.10	D59.11
D59.12	D59.13	D59.19	D66	D69.3	D69.41	D69.42
D69.49	D89.811	D89.812	D89.813	G04.81	G35	G36.0
G37.0	G37.5	G60.8	G61.89	G62.89	G64	G70.00
G70.01	L10.0	L10.1	L10.2	L10.3	L10.4	L10.5
L10.81	L10.89	L12.0	L12.1	L12.2	L12.31	L12.35
L12.8	L13.8	L13.9	M05.011	M05.012	M05.021	M05.022
M05.031	M05.032	M05.041	M05.042	M05.051	M05.052	M05.061
M05.062	M05.071	M05.072	M05.09	M05.111	M05.112	M05.121
M05.122	M05.131	M05.132	M05.141	M05.142	M05.151	M05.152
M05.161	M05.162	M05.171	M05.172	M05.19	M05.211	M05.212
M05.221	M05.222	M05.231	M05.232	M05.241	M05.242	M05.251
M05.252	M05.261	M05.262	M05.271	M05.272	M05.29	M05.311
M05.312	M05.321	M05.322	M05.331	M05.332	M05.341	M05.342
M05.351	M05.352	M05.361	M05.362	M05.371	M05.372	M05.39
M05.411	M05.412	M05.421	M05.422	M05.431	M05.432	M05.441
M05.442	M05.451	M05.452	M05.461	M05.462	M05.471	M05.472
M05.49	M05.511	M05.512	M05.521	M05.522	M05.531	M05.532
M05.541	M05.542	M05.551	M05.552	M05.561	M05.562	M05.571
M05.572	M05.59	M05.611	M05.612	M05.621	M05.622	M05.631
M05.632	M05.641	M05.642	M05.651	M05.652	M05.661	M05.662
M05.671	M05.672	M05.69	M05.711	M05.712	M05.721	M05.722
M05.731	M05.732	M05.741	M05.742	M05.751	M05.752	M05.761
M05.762	M05.771	M05.772	M05.79	M05.811	M05.812	M05.821
M05.822	M05.831	M05.832	M05.841	M05.842	M05.851	M05.852
M05.861	M05.862	M05.871	M05.872	M05.89	M05.9	M06.011
M06.012	M06.021	M06.022	M06.031	M06.032	M06.041	M06.042
M06.051	M06.052	M06.061	M06.062	M06.071	M06.072	M06.08
M06.09	M06.1	M06.211	M06.212	M06.221	M06.222	M06.231
M06.232	M06.241	M06.242	M06.251	M06.252	M06.262	M06.271
M06.272	M06.28	M06.29	M06.311	M06.312	M06.321	M06.322
M06.331	M06.332	M06.341	M06.342	M06.351	M06.352	M06.361
M06.362	M06.371	M06.372	M06.38	M06.39	M06.811	M06.812
M06.821	M06.822	M06.831	M06.832	M06.841	M06.842	M06.851
M06.852	M06.861	M06.862	M06.871	M06.872	M06.88	M06.89
M06.9	M30.0	M30.1	M30.2	M30.8	M31.30	M31.31
M31.7	M32.0	M32.10	M32.11	M32.12	M32.13	M32.14
M32.15	M32.19	M32.8	M32.9	M33.20	M33.21	M33.22
M33.29	M33.90	M33.91	M33.92	M33.93	M33.99	M34.0
M34.1	M34.2	M34.81	M34.82	M34.83	M34.9	M35.00
M35.01	M35.02	M35.03	M35.04	M35.09	N01.0	N01.1
N01.2	N02.0	N02.1	N02.2	N02.3	N02.5	N02.8
N02.9	N03.0	N03.2	N04.0	N04.1	N04.2	N04.3
N04.4	N04.5	N04.6	N04.7	N04.8	N04.9	N05.0
N05.2	N07.0	N07.1	N07.2	N08	R59.0	R59.1
R59.9	T86.09	Z85.71	Z85.72	Z85.79	Z94.81

Covered Diagnosis Codes for Procedure Code J9311

C79.63	C82.00	C82.01	C82.02	C82.03	C82.04	C82.05
C82.06	C82.07	C82.08	C82.09	C82.10	C82.11	C82.12
C82.13	C82.14	C82.15	C82.16	C82.17	C82.18	C82.19
C82.20	C82.21	C82.22	C82.23	C82.24	C82.25	C82.26
C82.27	C82.28	C82.29	C82.30	C82.31	C82.32	C82.33
C82.34	C82.35	C82.36	C82.37	C82.38	C82.39	C82.40
C82.41	C82.42	C82.43	C82.44	C82.45	C82.46	C82.47
C82.48	C82.49	C82.50	C82.51	C82.52	C82.53	C82.54
C82.55	C82.56	C82.57	C82.58	C82.59	C82.60	C82.61
C82.62	C82.63	C82.64	C82.65	C82.66	C82.67	C82.68
C82.69	C82.80	C82.81	C82.82	C82.83	C82.84	C82.85
C82.86	C82.87	C82.88	C82.89	C82.90	C82.91	C82.92
C82.93	C82.94	C82.95	C82.96	C82.97	C82.98	C82.99
C83.00	C83.01	C83.02	C83.03	C83.04	C83.05	C83.06
C83.07	C83.08	C83.09	C83.10	C83.11	C83.12	C83.13
C83.14	C83.15	C83.16	C83.17	C83.18	C83.19	C83.30
C83.31	C83.32	C83.33	C83.34	C83.35	C83.36	C83.37
C83.38	C83.39	C83.80	C83.81	C83.82	C83.83	C83.84
C83.85	C83.86	C83.87	C83.88	C83.89	C85.20	C85.21
C85.22	C85.23	C85.24	C85.25	C85.26	C85.27	C85.28
C85.29	C85.80	C85.81	C85.82	C85.83	C85.84	C85.85
C85.86	C85.87	C85.88	C85.89	C88.4	C91.10	C91.12
C91.40	C91.42	D36.0	D47.Z1	D47.Z2	R59.0	R59.1
R59.9

Covered Diagnosis Codes for Q5115

C82.00	C82.01	C82.02	C82.03	C82.04	C82.05	C82.06
C82.07	C82.08	C82.09	C82.10	C82.11	C82.12	C82.13
C82.14	C82.15	C82.16	C82.17	C82.18	C82.19	C82.20
C82.21	C82.22	C82.23	C82.24	C82.25	C82.26	C82.27
C82.28	C82.29	C82.30	C82.31	C82.32	C82.33	C82.34
C82.35	C82.36	C82.37	C82.38	C82.39	C82.40	C82.41
C82.42	C82.43	C82.44	C82.45	C82.46	C82.47	C82.48
C82.49	C82.50	C82.51	C82.52	C82.53	C82.54	C82.55
C82.56	C82.57	C82.58	C82.59	C82.60	C82.61	C82.62
C82.63	C82.64	C82.65	C82.66	C82.67	C82.68	C82.69
C82.80	C82.81	C82.82	C82.83	C82.84	C82.85	C82.86
C82.87	C82.88	C82.89	C82.90	C82.91	C82.92	C82.93
C82.94	C82.95	C82.96	C82.97	C82.98	C82.99	C83.00
C83.01	C83.02	C83.03	C83.04	C83.05	C83.06	C83.07
C83.08	C83.09	C83.10	C83.11	C83.12	C83.13	C83.14
C83.15	C83.16	C83.17	C83.18	C83.19	C83.30	C83.31
C83.32	C83.33	C83.34	C83.35	C83.36	C83.37	C83.38
C83.39	C83.70	C83.71	C83.72	C83.73	C83.74	C83.75
C83.76	C83.77	C83.78	C83.79	C83.80	C83.81	C83.82
C83.83	C83.84	C83.85	C83.86	C83.87	C83.88	C83.89
C83.90	C83.91	C83.92	C83.93	C83.94	C83.95	C83.96
C83.97	C83.98	C83.99	C85.10	C85.11	C85.12	C85.13
C85.14	C85.15	C85.16	C85.17	C85.18	C85.19	C85.20
C85.21	C85.22	C85.23	C85.24	C85.25	C85.26	C85.27
C85.28	C85.29	C85.80	C85.81	C85.82	C85.83	C85.84
C85.85	C85.86	C85.87	C85.88	C85.89	C88.4	C91.10
C91.40	C91.42	D36.0	D47.Z1	D47.Z2	M05.011	M05.012
M05.021	M05.022	M05.031	M05.032	M05.041	M05.042	M05.051
M05.052	M05.061	M05.062	M05.071	M05.072	M05.09	M05.111
M05.112	M05.121	M05.122	M05.131	M05.132	M05.141	M05.142
M05.151	M05.152	M05.161	M05.162	M05.171	M05.172	M05.19
M05.211	M05.212	M05.221	M05.222	M05.231	M05.232	M05.241
M05.242	M05.251	M05.252	M05.261	M05.262	M05.271	M05.272
M05.29	M05.311	M05.312	M05.321	M05.322	M05.331	M05.332
M05.341	M05.342	M05.351	M05.352	M05.361	M05.362	M05.371
M05.372	M05.39	M05.411	M05.412	M05.421	M05.422	M05.431
M05.432	M05.441	M05.442	M05.451	M05.452	M05.461	M05.462
M05.471	M05.472	M05.49	M05.511	M05.512	M05.521	M05.522
M05.531	M05.532	M05.541	M05.542	M05.551	M05.552	M05.561
M05.562	M05.571	M05.572	M05.59	M05.611	M05.612	M05.621
M05.622	M05.631	M05.632	M05.641	M05.642	M05.651	M05.652
M05.661	M05.662	M05.671	M05.672	M05.69	M05.711	M05.712
M05.721	M05.722	M05.731	M05.732	M05.741	M05.742	M05.751
M05.752	M05.761	M05.762	M05.771	M05.772	M05.79	M05.811
M05.812	M05.821	M05.822	M05.831	M05.832	M05.841	M05.842
M05.851	M05.852	M05.861	M05.862	M05.871	M05.872	M05.89
M05.9	M06.011	M06.012	M06.021	M06.022	M06.031	M06.032
M06.041	M06.042	M06.051	M06.052	M06.061	M06.062	M06.071
M06.072	M06.08	M06.09	M06.1	M06.211	M06.212	M06.221
M06.222	M06.231	M06.232	M06.241	M06.242	M06.251	M06.252
M06.262	M06.271	M06.272	M06.28	M06.29	M06.311	M06.312
M06.321	M06.322	M06.331	M06.332	M06.341	M06.342	M06.351
M06.352	M06.361	M06.362	M06.371	M06.372	M06.38	M06.39
M06.811	M06.812	M06.821	M06.822	M06.831	M06.832	M06.841
M06.842	M06.851	M06.852	M06.861	M06.862	M06.871	M06.872
M06.88	M06.89	M06.9	M31.30	M31.31	M31.7	R59.0
R59.1	R59.9

Covered Diagnosis Codes for Q5119 and Q5123

C82.00	C82.01	C82.02	C82.03	C82.04	C82.05	C82.06
C82.07	C82.08	C82.09	C82.10	C82.11	C82.12	C82.13
C82.14	C82.15	C82.16	C82.17	C82.18	C82.19	C82.20
C82.21	C82.22	C82.23	C82.24	C82.25	C82.26	C82.27
C82.28	C82.29	C82.30	C82.31	C82.32	C82.33	C82.34
C82.35	C82.36	C82.37	C82.38	C82.39	C82.40	C82.41
C82.42	C82.43	C82.44	C82.45	C82.46	C82.47	C82.48
C82.49	C82.50	C82.51	C82.52	C82.53	C82.54	C82.55
C82.56	C82.57	C82.58	C82.59	C82.60	C82.61	C82.62
C82.63	C82.64	C82.65	C82.66	C82.67	C82.68	C82.69
C82.80	C82.81	C82.82	C82.83	C82.84	C82.85	C82.86
C82.87	C82.88	C82.89	C82.90	C82.91	C82.92	C82.93
C82.94	C82.95	C82.96	C82.97	C82.98	C82.99	C83.00
C83.01	C83.02	C83.03	C83.04	C83.05	C83.06	C83.07
C83.08	C83.09	C83.10	C83.11	C83.12	C83.13	C83.14
C83.15	C83.16	C83.17	C83.18	C83.19	C83.30	C83.31
C83.32	C83.33	C83.34	C83.35	C83.36	C83.37	C83.38
C83.39	C83.70	C83.71	C83.72	C83.73	C83.74	C83.75
C83.76	C83.77	C83.78	C83.79	C83.80	C83.81	C83.82
C83.83	C83.84	C83.85	C83.86	C83.87	C83.88	C83.89
C83.90	C83.91	C83.92	C83.93	C83.94	C83.95	C83.96
C83.97	C83.98	C83.99	C85.10	C85.11	C85.12	C85.13
C85.14	C85.15	C85.16	C85.17	C85.18	C85.19	C85.20
C85.21	C85.22	C85.23	C85.24	C85.25	C85.26	C85.27
C85.28	C85.29	C85.80	C85.81	C85.82	C85.83	C85.84
C85.85	C85.86	C85.87	C85.88	C85.89	C88.4	C91.10
C91.40	C91.42	D36.0	D47.Z1	D47.Z2	M31.30	M31.7
R59.0	R59.1	R59.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020Added rituximab-pvvr (Ruxience) for 18 years and older, added additional FDA indications and NCCN recommendations for biosimilar products

Internal Medical Policy Committee 5-19-2020 Added additional indication to TTP criteria

Internal Medical Policy Committee 7-22-2020 Added new code, Q5119 for rituximab-pvvr (Ruxience)

Internal Medical Policy Committee 9-21-2020 Updated criteria and diagnosis codes, separated criteria and diagnosis codes for Truxima and Ruxience

Internal Medical Policy Committee 3-17-2021 Added rituximab-arrx (Riabni) to policy and updated NCCN recommendations for rituximab-abbs (Truxima) and rituximab-pvvr (Ruxience)

Internal Medical Policy Committee 7-22-2021 Added new code, Q5123 for rituximab-arrx (Riabni) to policy effective 7-1-2021, updated NCCN recommendations

Internal Medical Policy Committee 9-21-2021 Added additional NCCN recommendations for rituximab-abbs (Truxima), rituximab-pvvr (Ruxience) or rituximab-arrx (Riabni), replaced characters with words and updated diagnosis codes

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-038-027

Section: Injections

Effective Date: July 01, 2018

Revised Date: May 27, 2021

Revision Effective Date: July 01, 2021

Last Reviewed: July 22, 2021

Archived Date: September 30, 2021

Description

Rituximab (Rituxan^®) is a genetically engineered chimeric murine/human monoclonal antibody. It binds specifically to the antigen CD20 (human B-lymphocyte-restricted differentiation antigen, Bp35). This antigen is a hydrophobic transmembrane protein that is located on pre-B and mature B lymphocytes. It is also expressed on more than 90% of B-cell non-Hodgkin's lymphomas, but it is not expressed on hematopoietic stem cells, pro-B cells, normal plasma cells, or other normal tissues.

Rituximab-abbs (Truxima®), rituximab-arrx (Riabni™), and rituximab-pvvr (Ruxience) are biosimilars of rituximab (Rituxan).

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Rituximab (Rituxan)

Food and Drug Administration (FDA) Approved Indications

Rituximab (Rituxan) may be considered medically necessary for ANY of the following indications:

Antineutrophil Cytoplasmic Antibody-Associated Vasculitides (Granulomatosis with Polyangiitis [Wegener Granulomatosis] and Microscopic Polyangiitis)

Treatment of individuals with antineutrophil cytoplasmic antibody-associated vasculitides (i.e., granulomatosis with polyangiitis (GPA) [Wegener granulomatosis] and microscopic polyangiitis), in combination with glucocorticoids; or

Chronic Lymphocytic Leukemia (CLL)

Treatment of previously untreated and previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide (FC); or

Non-Hodgkin's Lymphoma (NHL)

Treatment of NHL in any of the following:

Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent; or
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in individuals achieving a complete or partial response to rituximab (Rituxan) in combination with chemotherapy, as single-agent maintenance therapy; or
Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or
Previously untreated diffuse large B-cell, CD20-positive NHL in combination with (cyclophosphamide, doxorubicin, vincristine, and prednisone) (CHOP) or other anthracycline-based chemotherapy regimens; or

Pemphigus Vulgaris (PV)

Treatment of moderate to severe treatment-refractory PV in individuals 18 years or older; or

Rheumatoid Arthritis (RA)

Treatment of individuals 18 years of age or older with RA who meet the following criteria:
- Individual has had an inadequate response to one (1) or more tumor necrosis factor inhibitors, or is not suitable for treatment with tumor necrosis factor inhibitors; or
- Combination therapy with methotrexate or other conventional synthetic DMARD not applicable to individuals who have had an inadequate response to methotrexate or other conventional synthetic DMARDs.
- RA is moderately to severely active (e.g., greater than or equal to eight (8) swollen and tender joints); and
- Rituximab (Rituxan) is administered in combination with methotrexate, or other conventional synthetic disease-modifying anti-rheumatic drug (DMARD) if methotrexate is contraindicated; and

Procedure Codes

J9312

Other clinically supported indications

Rituximab (Rituxan) may be considered medically necessary for ANY of the following off-label indications:

Autoimmune Hemolytic Anemia (AIHA)

Warm AIHA in glucocorticoid-refractory or glucocorticoid-dependent individuals; or
Cold agglutination syndrome; or

Churg-Strauss Syndrome (Eosinophilic Granulomatosis with Polyangiitis)

First-line treatment in combination with glucocorticoids for individuals with severe (organ-threatening) disease; or
Add-on therapy for treatment-refractory disease; or

Epstein-Barr virus disease; Prophylaxis - Hemopoietic stem cell transplant

Prophylaxis for Epstein Barr virus infection in pediatric individuals undergoing hematopoietic stem cell transplant; or

Evans syndrome (Pediatric only)

Treatment for Evans syndrome refractory to immunosuppressive therapy; or

Hemophilia

Treatment of individuals 18 years of age or older for hemophilia with acquired inhibitors in individuals who are refractory to conventional first line treatments (i.e. immunosuppression with prednisone and cyclophosphamide); or

Hepatitis C Virus‒Associated Cryoglobulinemic Vasculitis

As add-on therapy for individuals with hepatitis C virus‒associated cryoglobulinemic vasculitis who have:
- Active disease resistant to antiviral drugs; or
- Severe or life-threatening cryoglobulinemic vasculitis; or

Idiopathic Membranous Nephropathy

As treatment for idiopathic membranous nephropathy; or

Immune thrombocytopenia, previously treated (Pediatric only)

Treatment for pediatric individuals with previously treated primary and secondary immune thrombocytopenia; or

Inflammatory Myopathy (Idiopathic)

Treatment for individuals 18 years of age or older who have failed to respond to, or are intolerant to, another immunosuppressant (e.g. methotrexate) with refractory idiopathic inflammatory myopathy; or

Lupus Nephritis

As add-on therapy for lupus nephritis refractory to standard first-line treatment regimen; or

Microscopic polyarteritis nodosa (Adult only)

Treatment for microscopic polyarteritis nodosa in combination with glucocorticoids; or

Minimal change disease (Pediatric only)

Treatment for remission induction and maintenance of remission in pediatric individuals who have refractory, steroid-dependent or steroid-resistant minimal change disease; or

Multiple Sclerosis (Primary Progressive)

Treatment for individuals 18 years of age or older with primary progressive multiple sclerosis who have gadolinium brain lesions at baseline and have failed treatment with ocrelizumab; or

Multiple Sclerosis (Relapsing Remitting)

Treatment of relapsing remitting multiple sclerosis when the individuals has experienced therapeutic failure, intolerance, or contraindication to two (2) alternative drug therapies indicated for the treatment of multiple sclerosis (e.g. Avonex, Aubagio, Gilenya, etc.); or

Myasthenia Gravis

Treatment for individuals 18 years of age or older with myasthenia gravis refractory to conventional therapy (e.g., azathioprine, corticosteroids, immunosuppressants, plasma exchange, IV immunoglobulin, thymectomy); or

Myopathy, Idiopathic Inflammatory

Treatment for refractory idiopathic inflammatory myopathy in individuals who have failed to respond to, or are intolerant to, another immunosuppressant (e.g. methotrexate); or

Neuromyelitis Optica

Rituximab (Rituxan) may be considered medically necessary as treatment for neuromyelitis optica for relapse prevention; or

Pemphigoid Diseases

Treatment for ANY of the following pemphigoid diseases in treatment-refractory individuals:
- Bullous pemphigoid; or
- Mucous membrane pemphigoid, including ocular cicatricial pemphigoid; or
- Epidermolysis bullosa acquisita; or

Pemphigus Diseases

Treatment for pemphigus diseases (i.e., pemphigus vulgaris, paraneoplastic pemphigus); or

Pemphigus Foliaceus

Treatment for individuals 18 years of age or older with pemphigus foliaceus in combination with a tapering course of corticosteroids; or

Sjogren's Syndrome (Primary)

Treatment for individuals 18 years of age or older with primary Sjogren's syndrome as a one (1) time course of treatment over 15 days; or

Systemic Lupus Erythematosus

Treatment as add-on therapy for systemic lupus erythematosus refractory to immunosuppressive therapy; or

Systemic Sclerosis (Scleroderma)

Treatment for systemic sclerosis (scleroderma) in individuals refractory to first-line treatment; or

Thrombocytopenic purpura (Idiopathic)

Treatment for individuals 18 years of age or older with idiopathic thrombocytopenic purpura refractory to first-line therapy (e.g., corticosteroids, IV immune globulin, splenectomy, etc.) who are at risk of bleeding (grade 2C); or

Thrombotic Thrombocytopenic Purpura

Treatment in combination with steroids and plasma exchange in individuals 18 years of age or older with refractory thrombotic thrombocytopenic purpura (i.e., lack of response to plasma exchange therapy and glucocorticoids).

Procedure Codes

J9312

National Comprehensive Cancer Network (NCCN) Approved Recommendations

Rituximab (Rituxan) may be considered medically necessary for ANY of the following indications:

Acute Lymphoblastic Leukemia (ALL)

Induction/consolidation therapy for Philadelphia chromosome-negative ALL in adolescent and young adult (AYA) and adult individuals less than 65 years of age as a component of:
- GRAALL-2005 regimen (daunorubicin, vincristine, prednisone, pegaspargase, and cyclophosphamide) with rituximab for CD20-positive disease (individuals aged less than 60 years); or
- HyperCVAD (hyper-fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone, alternating with high-dose methotrexate and cytarabine), with or without rituximab for CD20-positive disease; or
Induction therapy for Philadelphia chromosome-negative ALL in adults aged greater than or equal to 65 years as a component of GMALL (idarubicin, dexamethasone, vincristine, cyclophosphamide, and cytarabine, with or without rituximab for CD20-positive disease) (moderate intensity); or
Therapy for relapsed/refractory Philadelphia chromosome-negative ALL or for relapsed/refractory Philadelphia chromosome-positive ALL refractory to TKIs as a component of MOpAD regimen (methotrexate, vincristine, pegaspargase, dexamethasone) with rituximab for CD20-positive disease; or
Therapy for relapsed/refractory Philadelphia chromosome-positive ALL as a component of MOpAD regimen (methotrexate, vincristine, pegaspargase, dexamethasone) with rituximab for CD20-positive disease and TKI; or

B-Cell Lymphoma - AIDS-Related

Treatment in combination with growth factor support for AIDS-related Burkitt lymphoma as a component of:
- DA-EPOCH-R (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- Modified CODOX-M (cyclophosphamide, doxorubicin, and vincristine, with intrathecal methotrexate and cytarabine followed by high-dose systemic methotrexate) regimen alternating with IVAC (ifosfamide, cytarabine, etoposide, and intrathecal methotrexate) regimen with rituximab; or
In combination with growth factor support for AIDS-related Burkitt lymphoma as a component of R-HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine) regimen; or
Second-line therapy for relapse of AIDS-related Burkitt lymphoma as a component of:
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab (if not previously given as first-line therapy); or
- RICE (rituximab, ifosfamide, carboplatin, and etoposide) regimen in combination with intrathecal methotrexate (if not previously given); or
- RIVAC (rituximab, ifosfamide, cytarabine, etoposide) regimen in combination with intrathecal methotrexate (if not previously given); or
- RGDP (rituximab, gemcitabine, dexamethasone, cisplatin) regimen; or
- High-dose cytarabine and rituximab regimen; or
Treatment In combination with growth factor support for CD20+ AIDS-related diffuse large B-cell lymphoma (DLBCL) primary effusion lymphoma and HHV8-positive DLBCL, not otherwise specified (NOS) as a component of R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
In combination with growth factor support for CD20+ AIDS-related diffuse large B-cell lymphoma and HHV8-positive DLBCL, not otherwise specified (NOS) as a component of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with rituximab; or
Used for relapsed AIDS-related DLBCL, HHV8-positive DLBCL, not otherwise specified (NOS), and primary effusion lymphoma in combination with bortezomib-ICE (ifosfamide, carboplatin, and etoposide) regimen; or
Second-line therapy or subsequent therapy for relapse of AIDS-related DLBCL, primary effusion lymphoma, and HHV8-positive DLBCL, not otherwise specified (NOS):
- For individuals with intention to proceed to transplant as a component of DHAP (dexamethasone, cisplatin, and cytarabine), DHAX (dexamethasone, cytarabine, and oxaliplatin), ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin), GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin), GemOX (gemcitabine and oxaliplatin), ICE (ifosfamide, carboplatin, and etoposide), or MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen with rituximab; or
- In non-candidates for transplant as a single agent, in combination with polatuzumab vedotin-piiq with or without bendamustine (greater than or equal to two (2) prior therapies), with lenalidomide (for non-germinal center DLBCL) or bendamustine, with gemcitabine and vinorelbine, or as a component of CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine), dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), CEOP (cyclophosphamide, etoposide, vincristine, and prednisone), GDP, or GemOX regimen with rituximab; or

B-Cell Lymphomas - Burkitt Lymphoma

Induction therapy for low-risk disease for individuals less than 60 years of age as a component of:
- CODOX-M (cyclophosphamide, doxorubicin, and vincristine, with intrathecal methotrexate and cytarabine followed by high-dose systemic methotrexate) regimen (original or modified) regimen with rituximab; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate; or
- HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab(regimen includes intrathecal therapy); or
Induction therapy for high-risk disease in individuals less than 60 years of age as a component of:
- CODOX-M (cyclophosphamide, doxorubicin, and vincristine, with intrathecal methotrexate and cytarabine followed by high-dose systemic methotrexate) regimen (original or modified) alternating with IVAC (ifosfamide, cytarabine, etoposide, and intrathecal methotrexate) regimen with rituximab; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate for individuals not able to tolerate aggressive therapy; or
- Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab (regimen includes intrathecal therapy); or
Induction therapy for low-risk and high-risk disease in individuals 60 years of age or older as a component of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate; or
Used as a component of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab and intrathecal methotrexate, RICE (rituximab, ifosfamide, carboplatin, and etoposide) regimen with intrathecal methotrexate if not previously given, RIVAC (rituximab, ifosfamide, cytarabine, and etoposide) regimen with intrathecal methotrexate if not previously given:
- As second-line therapy for relapse of Burkitt lymphoma greater than 6-18 months following appropriate first-line therapy; or
- For individuals with partial response to second-line therapy as additional therapy (if not previously given) for relapse or refractory disease; or
Second-line therapy for individuals with disease relapse greater than 6-18 months after appropriate first-line therapy or for individuals with partial response to second-line therapy as additional therapy (if not previously given) for relapsed or refractory disease:
- As a component of RGDP (rituximab, gemcitabine, dexamethasone, and cisplatin) regimen; or
- As a component of high-dose cytarabine with rituximab regimen; or

B-Cell Lymphomas - Castleman's Disease (CD)

Used for unicentric CD with or without prednisone and/or cyclophosphamide:
- For surgically unresectable disease; or
- For symptomatic disease following incomplete resection; or
- As second-line therapy for relapsed or refractory disease; or
Therapy for active multicentric CD with no organ failure with or without prednisone for individuals who are human immunodeficiency virus-negative and human herpesvirus-8-negative:
- As primary treatment; or
- For relapsed disease; or
- If no response to primary treatment; or
Therapy for active multicentric CD with no organ failure with or without liposomal doxorubicin and/or prednisone for individuals who are human herpesvirus-8-positive:
- As preferred** primary treatment; or
- For relapsed disease; or
- If no response to primary treatment; or
Used with or without prednisone for active multicentric CD with no organ failure for progression greater than or equal to six (6) months following completion of rituximab; or
Primary treatment for multicentric CD for individuals with fulminant human herpesvirus-8 with or without organ failure:
- In combination with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- In combination with CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) regimen; or
- In combination with CVP (cyclophosphamide, vincristine, and prednisone) regimen; or
- In combination with Liposomal doxorubicin; or
- As a single agent if individual is not a candidate for combination therapy; or
Treatment for refractory or progressive multicentric CD in combination with liposomal doxorubicin or with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone), or CVP (cyclophosphamide, vincristine, and prednisone) regimen:
- As initial treatment; or
- If no response to initial treatment for refractory or progressive disease; or
Subsequent therapy for multicentric CD that has progressed following treatment of relapsed/refractory or progressive disease in combination with:
- Bortezomib; or
- Lenalidomide; or
- Thalidomide; or

B-Cell Lymphomas - Diffuse Large B-Cell Lymphoma (DLBCL)

First-line therapy for stage I-II disease as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
First-line therapy for stage I-II disease for individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
First-line therapy for stage I-II disease for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
First-line therapy for stage III-IV disease as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
First-line therapy for stage III-IV disease in individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen or
First-line therapy for stage III-IV disease for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
Second-line or subsequent therapy for partial response, no response, relapsed, progressive, or refractory disease in individuals with intention to proceed to transplant as a component of:
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen with rituximab; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen with rituximab,
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen with rituximab; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen with rituximab; or
- GemOX (gemcitabine and oxaliplatin) regimen with rituximab; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen with rituximab; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen with rituximab; or
Second-line or subsequent therapy for partial response, no response, relapsed, progressive, or refractory disease in non-candidates for transplant:
- As a single agent; or
- In combination with lenalidomide (non-germinal center lymphoma); or
- In combination with bendamustine; or
- In combination with Polatuzumab vendotin-piiq with or without bendamustine after greater than or equal to two (2) prior therapies; or
- As a component of CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) with rituximab regimen; or
- As a component of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) with rituximab regimen; or
- As a component of CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) with rituximab regimen; or
- As a component of GDP with rituximab regimen; or
- As a component of GemOX with rituximab regimen; or
- As a component of gemcitabine and vinorelbine regimens with rituximab; or
First-line therapy for primary mediastinal large B-cell lymphoma as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- Dose-dense RCHOP regimen followed by ICE (ifosfamide, carboplatin, and etoposide) regimen; or
First-line therapy for grey zone lymphoma as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
First-line therapy for grey zone lymphoma for individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
First-line therapy for grey zone lymphoma for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
Treatment of primary cutaneous DLBCL, leg type as first-line with involved site radiation therapy or as second-line therapy (if not previously received) for solitary regional T 1-2 disease, or as firs-line therapy for generalized cutaneous, T3 disease:
- As a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
Treatment of primary cutaneous DLBCL, leg type as first-line with involved site radiation therapy or as second-line therapy (if not previously received) for solitary regional T 1-2 disease, or as firs-line therapy for generalized cutaneous, T3 disease in individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
Treatment of primary cutaneous DLBCL, leg type as first-line with involved site radiation therapy or as second-line therapy (if not previously received) for solitary regional T 1-2 disease, or as firs-line therapy for generalized cutaneous, T3 disease for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or
First-line therapy for extracutaneous primary cutaneous DLBCL, leg type as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
First-line therapy for extracutaneous primary cutaneous DLBCL, leg type for individuals with poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone) regimen; or
First-line therapy for extracutaneous primary cutaneous DLBCL, leg type for very frail individuals and individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP; or
- RGCVP regimen; or

B-Cell Lymphomas -Follicular Lymphoma (grade 1-2)

First-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for individuals with the indications for treatment with stage III or IV disease as:
- A component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- A component of RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- In combination with bendamustine or lenalidomide; or
Used as a single agent in elderly or infirm individuals when tolerability of combination chemotherapy is a concern as:
- First-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for individuals with indications for treatment with stage III or IV disease; or
- Second-line or subsequent therapy (if not previously given as first-line) for refractory or progressive disease in individuals with indications for treatment; or
Used in elderly or infirm individuals with indications for treatment in combination with chlorambucil or in combination with cyclophosphamide as:
- First-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for individuals with indications for treatment with stage III or IV disease; or
- Second-line or subsequent therapy (if not previously given as first-line) for refractory or progressive disease in individuals with indications for treatment; or
First-line therapy for stage I, contiguous stage II non-contiguous stage II disease, or for individuals with indications for treatment with stage III or IV disease as a single agent in individuals that were initially observed and have progressed with a low tumor burden; or
First-line therapy for stage I, II pediatric-type follicular lymphoma in adults with extensive local disease who are not candidates for excision or involved site radiation therapy as a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) regimen; or
Second-line or subsequent therapy for refractory or progressive disease in individuals with indications for treatment as a single agent or in combination with:
- Bendamustine (if not previously given as first-line); or
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen (if not previously given as first-line); or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen ( if not previously given as first-line); or
- Lenalidomide (if not previously given as first line); or
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- Gemcitabine and vinorelbine; or
- Polatuzumab vendotin-piiq with or without bendamustine; or
Treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) and rituximab regimen; or
Treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy and have poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine and prednisolone) regimen; or
Treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy and are very frail and for individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP regimen; or
- RGCVP regimen; or
Used in combination with polatuzumab vedotin-piiq with or without bendamustine as treatment of histologic transformation to DLBCL without translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy prior to histologic transformation and have no response or progressive disease after chemoimmunotherapy; or
Treatment of histologic transformation to DLBCL with translocations of MYC and BCL2 and/or BCL6 in individuals who have received minimal or no prior chemotherapy as a component of:
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- R-CODOX-M (rituximab, cyclophosphamide, vincristine, and doxorubicin with methotrexate) regimen alternating with R-IVAC (rituximab, ifosfamide, etoposide, and cytarabine) regimen; or
Treatment of histologic transformation to DLBCL in individuals who have received multiple lines of chemoimmunotherapy for indolent or transformed disease as a single agent or in combination with:
- Bendamustine; or
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- Lenalidomide; or
- Gemcitabine and vinorelbine; or
- Polatuzumab vendotin-piiq with or without bendamustine; or
First-line consolidation therapy in individuals with indications for treatment if initially treated with single-agent rituximab; or
Maintenance therapy:
- As first-line consolidation or extended dosing in individuals initially presenting with high tumor burden (stage III, IV) who achieve a complete or partial response following treatment with RCHOP (rituximab, cyclophosphamide, doxorubicin, and prednisone) regimen or RCVP (rituximab, cyclophosphamide, vincristine and prednisone) regimen; or
- Second-line consolidation or extended dosing; or
- Can be considered for individuals with histologic transformation to DLBCL that is coexisting with extensive follicular lymphoma who achieve a complete response to chemoimmunotherapy; or

B-Cell Lymphomas - Gastric MALT Lymphoma

Initial therapy (if involved site radiation therapy is contraindicated) as a single agent stage I₁, or I₂, or stage II₁disease in individuals who are H-pylori-positive and t(11;18) positive or who are H-pylori-negative; or
Treatment for individuals with indications for treatment as a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen, RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen, or in combination with bendamustine:
- As first-line therapy for stage IIE, or II₂, or stage IV disease (distant nodal, advanced stage); or
- As additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and involved site radiation therapy (ISRT); or
- As additional therapy after ISRT or rituximab alone for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
Used as a single agent in individuals with indications for treatment as:
- First-line therapy for stage IIE, or II₂, or stage IV (distant nodal or advanced stage); or
- Additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and ISRT; or
- Additional therapy after involved site radiation therapy ISRT alone for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
- second-line or subsequent therapy for recurrent or progressive disease (if longer duration of remission); or
Used in combination with lenalidomide for individuals with indications for treatment as:
- First-line therapy for stage IIE, or II₂, or stage IV disease (distant nodal or advanced stage); or
- Additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and ISRT; or
- Additional therapy after ISRT or rituximab alone) for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
Used as a single agent or in combination with chlorambucil or cyclophosphamide in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy for stage IIE, or II₂, or stage IV (distant nodal or advanced stage) disease; or
- Additional therapy for stage I₁, or I₂, or stage II₁H. pylori positive disease if repeat endoscopy shows no response or recurrence after antibiotic therapy and ISRT; or
- Additional therapy after ISRT or rituximab alone for stage I₁, or I₂, or stage II₁disease that is lymphoma positive after restaging with endoscopy; or
- Second-line or subsequent therapy for recurrent or progressive disease; or
Consolidation as optional first-line extended therapy in individuals initially treated with single agent rituximab; or
Second-line therapy or subsequent therapy for recurrent or progressive disease in individuals with indications for treatment:
- In combination with Bendamustine (not recommended if previously treated with bendamustine**); or
- As a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- As a component of RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- In combination with Lenalidomide (including for the elderly or infirm when tolerability of combination chemotherapy is a concern); or

B-Cell Lymphomas - High-Grade B-Cell Lymphomas

Used as induction therapy for high-grade B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma) or high-grade B-cell lymphomas, not otherwise specified as a component of:
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- R-CODOX-M (rituximab, cyclophosphamide, vincristine, and doxorubicin with methotrexate) regimen alternating with R-IVAC (rituximab, ifosfamide, etoposide, and cytarabine) regimen; or
Used as induction therapy for high-grade B-cell lymphomas, not otherwise specified* as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- R-CODOX-M (rituximab, cyclophosphamide, vincristine, and doxorubicin with methotrexate) regimen alternating with R-IVAC (rituximab, ifosfamide, etoposide, and cytarabine) regimen; or
Second-line or subsequent therapy for partial response, no response, relapsed, progressive, or refractory high-grade B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (Double/Triple Hit Lymphoma) in:
- Individuals with intention to proceed to transplant as a component of DHAP (dexamethasone, cisplatin, and cytarabine), DHAX (dexamethasone, cytarabine, and oxaliplatin), ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin), GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin), GemOX (gemcitabine and oxaliplatin), ICE (ifosfamide, carboplatin, and etoposide), or MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen with rituximab; or
- Non-candidates for transplant as a single agent, in combination with lenalidomide (non-germinal center lymphoma) or bendamustine, or as a component of CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine), dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), CEOP (cyclophosphamide, etoposide, vincristine, and prednisone), GDP, GemOX, or gemcitabine and vinorelbine regimen with rituximab; or
- Non-candidates for transplant in combination with polatuzumab vendotin-piiq with or without bendamustine after greater than or equal to two (2) prior therapies; or
Second-line and subsequent therapy for partial response, no response, relapsed, progressive, or refractory high-grade B-cell lymphoma, NOS, in:
- Individuals with intention to proceed to transplant as component of DHAP, DHAX, ESHAP, GDP, gemcitabine, dexamethasone, and carboplatin, GemOx, ICE, or MINE, regimen with rituximab; or
- Non-candidates for transplant as a single agent, in combination with lenalidomide (non-germinal center lymphoma) or bendamustine, or as a coponet of CEPP, dose-adjusted EPOCH, CEOP, GDP, gemcitabine, dexamethasone, and carboplatin, GemOx, or gemcitabine and vinorelbine regimen with rituximab; or
- Non-candidates for transplant in combination with polatuzumab vevedotin-piiq with or without bendamustine; or

*RCHOP has been associated with inferior outcomes for individuals with highgrade B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma)

B-Cell Lymphomas - Nongastric MALT Lymphoma (Noncutaneous)

First-line therapy for stage I-II disease in selected cases; or
First-line therapy for stage IV disease or recurrent stage I-II disease in individuals with indications for treatment as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- Bendamustine with rituximab; or
First-line therapy as a single agent or in combination with lenalidomide for stage IV disease or recurrent stage I-II disease in individuals with indications for treatment; or
Used as a single agent or in combination with chlorambucil or cyclophosphamide for stage IV disease or recurrent stage I-II disease in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy; or
- Second-line or subsequent therapy for recurrent or progressive disease; or
Second-line or subsequent therapy for recurrent or progressive disease in individuals with indications for treatment in:
- Bendamustine with rituximab; or
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
- Lenalidomide with rituximab (including for the elderly or infirm when tolerability of combination chemotherapy is a concern); or
Consolidation as optional first-line extended therapy; or
Second-line or subsequent therapy as a single agent for recurrent or progressive disease in individuals with indications for treatment (if longer duration of remission); or

B-Cell Lymphomas - Nodal Marginal Zone Lymphoma

Used as a single agent or in combination with chlorambucil or cyclophosphamide for stage I, contiguous stage II, non-contiguous stage II, or stage III, IV disease in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy; or
- Second-line or subsequent therapy; or
First-line therapy for stage I, contiguous stage II, non-contiguous stage II, or stage III, or IV disease in individuals with indications for treatment in combination with bendamustine or as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
First-line therapy as a single agent or in combination with lenalidomide for stage I, contiguous stage II, non-contiguous stage II, or stage III, IV disease in individuals with indications for treatment; or
Second-line or subsequent therapy for refractory or progressive disease in individuals with indications for treatment:
- In combination with bendamustine (not recommended if previously treated with bendamustine); or
- In combination with lenalidomide including for the elderly or infirm when tolerability of combination chemotherapy is a concern; or
- As a component of RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- As a component of RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
Consolidation as optional first-line extended therapy; or
Second-line or subsequent therapy as a single agent for refractory or progressive disease in individuals with indications for treatment (if longer duration of remission); or

B-Cell Lymphomas - Histologic Transformation of Marginal Zone Lymphoma to Diffuse Large B-Cell Lymphoma (DLBCL)

Treatment of individuals who have received minimal or no prior chemotherapy as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) and rituximab regimen; or
Treatment of individuals who have received minimal or no prior chemotherapy and have poor left ventricular function as a component of:
- RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen with rituximab; or
- RCEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone) regimen; or
- RGCVP (rituximab, gemcitabine, cyclophosphamide, vincristine and prednisolone) regimen; or
Treatment of individuals who have received minimal or no prior chemotherapy and are very frail and for individuals greater than 80 years of age with comorbidities as a component of:
- RCEPP regimen; or
- RCDOP regimen; or
- R-mini-CHOP regimen; or
- RGCVP regimen; or
Subsequent therapy for individuals who have received multiple lines of chemoimmunotherapy for indolent or transformed disease as a single agent, in combination with bendamustine, or as a component of:
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen with rituximab; or
- Lenalidomide; or
- Gemcitabine and vinorelbine; or
Used in combination with polatuzumab vedotin-piiq with or without bendamustine for individuals who have received multiple prior therapies including greater than or equal to two (2) lines of chemoimmunotherapy for indolent or transformed disease; or

B-Cell Lymphomas - Mantle Cell Lymphoma

Aggressive induction therapy for stage I-II disease that had a partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV TP53 mutation negative (Aggressive induction therapy followed by HDT/ASCR may not be appropriate for TP53 positive disease. ) disease in individuals who are candidates for high-dose therapy/autologous stem cell rescue (HDT/ASCR) as a component of:
- RDHA + platinum (rituximab, dexamethasone, cytarabine) + carboplatin, cisplatin, or oxaliplatin regimen; or
- Alternating RCHOP/RDHAP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)/(rituximab, dexamethasone, cytarabine, and cisplatin) regimen; or
- HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with high-dose methotrexate and cytarabine regimen with rituximab; or
- Bendamustine with rituximab followed by rituximab in combination with high-dose cytarabine; or
Aggressive induction therapy in combination with bendamustine for stage I-II disease that had a partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV TP53 mutation negative disease (Aggressive induction therapy followed by HDT/ASCR may not be appropriate for TP53 positive disease.); or
Less aggressive induction therapy for stage I-II disease as initial therapy (localized presentation, extremely rare), or for partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV TP53 mutation positive disease in individuals who are not candidates for high dose therapy/autologous stem cell rescue in combination with bendamustine or lenalidomide, or as a component of
- VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) regimen; or
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with rituximab; or
Less aggressive induction therapy for stage I-II disease (localized presentation, extremely rare) as initial therapy, or for partial response, progression, or relapse after initial treatment with involved site radiation therapy alone, or for aggressive stage II bulky, III, or IV TP53 mutation positive disease, or symptomatic indolent stage II bulky, III, or IV disease in individuals who are not candidates for high-dose therapy/autologous stem cell rescue as a component of:
- RBAC500 (rituximab, bendamustine, and cytarabine) regimen; or
- Modified HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab regimen in individuals older than 65 years
Single-agent maintenance therapy for aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV disease following complete or very good partial response to less aggressive induction therapy or high-dose therapy with autologous stem cell rescue; or
Second-line therapy for stage I-II disease or aggressive stage II bulky, III, or IV disease, or symptomatic indolent stage II bulky, III, or IV disease in individuals who have stable disease or partial response with substantial disease after induction therapy, or who have relapsed or progressed following prior treatment with chemoimmunotherapy:
- In combination with bendamustine (if not previously given); or
- As a component of RBAC500 (rituximab, bendamustine and cytarabine) regimen (f not previously given); or
- In combination with bortezomib; or
- As a component of DHAP (dexamethasone, cisplatin, and cytarabine) with rituximab regimen; or
- As a component of DHAOx (dexamethasone, cytarabine, and oxaliplatin) with rituximab regimen; or
- As a component of GemOx (gemcitabine, oxaliplatin) with rituximab regimen; or
- In combination with ibrutinib and lenalidomide; or
- In combination with venetoclax; or
Second-line or subsequent therapy for stage I-II, aggressive stage II bulky, III, or IV , or symptomatic indolent stage II bulky, III, or IV disease in individuals who have stable disease or partial response with substantial disease after induction therapy, or who have relapsed or progressed following prior chemoimmunotherapy:
- In combination with ibrutinib; or
- In combination with lenalidomide; or

B-Cell Lymphomas - Pediatric Aggressive Mature B-Cell Lymphomas

Induction therapy for individuals with greater than or equal to 20% reduction after COP reduction phase as a component of COG ANHL1131 regimen B/induction 1 and 2 with COPADM (cyclophosphamide, vincristine, prednisone, doxorubicin, methotrexate, and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen:
- For group B individuals with low-risk disease [stage I or II individuals who are not fully resected or any stage III individual with LDH 2 times the upper limit of normal (ULN)]; or
- For group B individuals with high-risk disease (any stage III individual with LDH greater than two (2) times upper limit of normal (ULN), and all non-CNS stage IV individuals with less than 25% bone marrow involvement); or
Consolidation therapy 1 for individuals with greater than or equal to 20% reduction after COP reduction phase as a component of COG ANHL1131 regimen B with CYM (cytarabine, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) with rituximab regimen:
- For group B individuals with low-risk disease [stage I or II individuals who are not fully resected or any stage III individual with LDH less than or equal to two (2) times the ULN]; or
- For group B individuals with high-risk disease (any stage III individual with LDH greater than two (2) times ULN, and all non-CNS stage IV individuals with less than 25% bone marrow involvement); or
Induction therapy as a component of COG ANHL1131 regimen C1/induction 1 and 2 with R-COPADM (cyclophosphamide, vincristine, prednisone, doxorubicin, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) with rituximab regimen for:
- Group B individuals with less than 20% size reduction after COP reduction phase; or
- Group C individuals with CNS negative disease after initial treatment with COP reduction phase; or
- Group C individuals with CNS positive and CSF negative or positive disease after initial treatment with COP reduction phase; or
Alternative induction therapy as a component of COG ANHL1131 regimen C3*/induction 1 and 2 with R-COPADM (cyclophosphamide, vincristine, prednisone, doxorubicin, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) with rituximab regimen for:
- Group C individuals with CNS and CSF positive disease; or
- Group C individuals on regimen C1 therapy with less than 20% size reduction after COP reduction phase; or
Consolidation therapy 1 and 2 as a component of COG ANHL1131 regimen C1 with R-CYVE (cytarabine, etoposide and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen:
- For group B individuals with less than complete response after first cycle of consolidation with CYM (cytarabine, methotrexate, and intrathecal therapy with methotrexate, cytarabine, and hydrocortisone) regimen; or
- For group C individuals with CNS negative disease; or
- For group C individuals with CNS positive disease, plus high-dose methotrexate and additional intrathecal therapy with methotrexate, cytarabine, and hydrocortisone after R-CYVE 1 only; or
Consolidation therapy 1 and 2 as a component of COG ANHL1131 regimen C3 with R-CYVE (cytarabine, etoposide and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen for group C individuals with CNS and CSF positive disease, plus high-dose methotrexate and additional intrathecal therapy with methotrexate, cytarabine, and hydrocortisone after R-CYVE 1 only; or
Preferred treatment for relapsed or refractory disease (if not previously received as a part of initial therapy) as a component of R-CYVE (cytarabine, etoposide, and intrathecal therapy with methotrexate and hydrocortisone) with rituximab regimen; or
Preferred treatment for relapsed or refractory disease as a component of R-ICE (ifosfamide, carboplatin, and etoposide) with rituximab regimen; or

B-Cell Lymphomas - Post-transplant Lymphoproliferative Disorder (PTLD)

Single-agent therapy as:
- First-line therapy for monomorphic (B-cell type) or polymorphic (B-cell type) PTLD; or
- Second-line therapy for partial response, persistent or progressive non-destructive lesions or for partial response, persistent or progressive monomorphic (B-cell type) PTLD if immunosuppressive was reduced in first-line therapy; or
- Maintenance therapy for polymorphic (B-cell type) PTLD achieving complete response on first-line therapy; or
Concurrent chemoimmunotherapy for CD20+ disease as a component of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with rituximab or as a component of CVP (cyclophosphamide, vincristine, and prednisone), CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine), or CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen with rituximab for frail individuals who cannot tolerate anthracyclines as:
- First-line therapy for monomorphic (B-cell type) or systemic polymorphic (B-cell type) PTLD; or
- Second-line therapy for partial response, persistent or progressive monomorphic (B-cell type) or polymorphic (B-cell type) PTLD; or
Sequential chemoimmunotherapy as a single agent followed by CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen with or without rituximab as:
- First-line therapy for monomorphic (B-cell type) or systemic polymorphic (B-cell type) PTLD; or
- Second-line therapy for persistent or progressive monomorphic (B-cell type) or polymorphic (B-cell type) PTLD; or
Used in combination with high-dose methotrexate for primary CNS PTLD (B-cell type); or
Second-line and subsequent therapy for individuals with partial response, persistent or progressive disease after receiving chemoimmunotherapy as first-line treatment for monomorphic PTLD (B-cell type) as a single agent or in combination with:
- Bendamustine; or
- DHAP (dexamethasone, cisplatin, and cytarabine) regimen; or
- DHAX (dexamethasone, cytarabine, and oxaliplatin) regimen; or
- ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) regimen; or
- GDP (gemcitabine, dexamethasone, and cisplatin or gemcitabine, dexamethasone, and carboplatin) regimen; or
- GemOX (gemcitabine and oxaliplatin) regimen; or
- ICE (ifosfamide, carboplatin, and etoposide) regimen; or
- MINE (mesna, ifosfamide, mitoxantrone, and etoposide) regimen; or
- CEPP (cyclophosphamide, etoposide, prednisone, and procarbazine) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) regimen; or
- CEOP (cyclophosphamide, etoposide, vincristine, and prednisone) regimen with rituximab; or
- Lenalidomide; or
- Gemcitabine and vinorelbine; or
- Polatuzumab vedotin-piiq with or without bendamustine (after greater than or equal to two (2) prior therapies; or

B-Cell Lymphoma - Primary Cutaneous

Therapy for primary cutaneous marginal zone or follicle center lymphoma with:
- Solitary/regional, T1-2 disease that is refractory to initial therapy; or
- Generalized disease (skin only), T3 disease; or

Central nervous system cancers - Leptomeningeal metastases

Intra-cerebrospinal fluid (CSF) treatment for leptomeningeal metastases from lymphomas for:
- Primary treatment in individuals with good risk status (KPS greater than or equal to 60, no major neurologic deficits, minimal systemic disease, and reasonable systemic treatment options if needed); or
- Maintenance treatment in individuals with negative CSF cytology or in clinically stable individuals with persistently positive CSF cytology; or
- Treatment in individuals with positive CSF cytology that have progressed after receiving prior treatment; or

Central Nervous System Cancers - Primary CNS Lymphoma:

Induction therapy:
- In combination with high-dose methotrexate; or
- In combination with high-dose methotrexate and temozolomide; or
- As a component of R-MPV (rituximab, methotrexate, procarbazine, and vincristine) regimen; or
- In combination with high-dose methotrexate and temozolomide followed by post-RT temozolomide; or
- As a single agent if individual is unsuitable for or intolerant to high-dose methotrexate; or
- In combination with temozolomide if individual is unsuitable for or intolerant to high-dose methotrexate; or
- In combination with lenalidomide if individual is unsuitable for or intolerant to high-dose methotrexate; or
Consider as intra-CSF therapy if CSF positive or spinal MRI positive as:
- Part of induction therapy; or
- Treatment alone or in combination with systemic chemotherapy for relapsed or refractory disease in individuals with prior WBRT; or
Consider for consolidation therapy as continuation of induction regimen in individuals with complete response or complete response unconfirmed (CRu) to induction therapy:
- In combination with high-dose methotrexate; or
- In combination with high-dose methotrexate and temozolomide; or
- As a component of R-MPV (rituximab, methotrexate, procarbazine, and vincristine) regimen; or
- In combination with high-dose methotrexate and temozolomide followed by post-RT temozolomide; or
Treatment as a single agent or in combination with temozolomide or lenalidomide for relapsed or refractory disease:
- May be considered in individuals who received prior whole brain radiation therapy (RT); or
- In individuals who received a prior high-dose methotrexate-based regimen without prior RT; or
- In combination with whole brain RT or involved field RT in individuals who received a prior high-dose methotrexate-based regimen without prior RT after no response or short response duration (less than 12 months) to prior regimen; or
- In individuals who received prior high-dose chemotherapy with stem cell rescue; or
Treatment in combination with high-dose methotrexate with or without ibrutinib for relapsed or refractory disease:
- In individuals who received prior whole brain radiation; or
- In individuals who received a prior high-dose methotrexate-based regimen without prior radiation therapy (RT) and a previous long response duration (greater than or equal to 12 months) to prior regimen; or

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

First-line therapy for disease without del(17p)/TP53 mutation in frail individuals with significant comorbidity (not able to tolerate purine analogs) or in individuals age greater than or equal 65 years and younger individuals with significant comorbidities (CrCl less than 70 ml/min) who have indications for treatment:
- In combination with high-dose methylprednisolone; or
- As a single agent; or
First-line therapy in combination with bendamustine for disease without del(17p)/TP53 mutation in individuals greater than or equal to 65 years of age and younger individuals with or without significant comorbidities who have indications for treatment (not recommended for frail individuals) ; or
First-line therapy for disease without del(17p)/TP53 mutation in individuals age less than 65 years without significant comorbidities who have indications for treatment:
- In combination with ibrutinib; or
- In combination with high-dose methylprednisolone; or
- As a component of PCR (pentostatin, cyclophosphamide, and rituximab) regimen; or
First-line therapy for disease with del(17p)/TP53 mutation in combination with alemtuzumab or high-dose methylprednisolone in individuals with indications for treatment; or
First line therapy for disease without del(17p)/TP53 mutations in individuals less than 65 years of age without significant comorbidities who have indications for treatment as a component of:
- FCR (fludarabine, cyclophosphamide, and rituximab) regimen (for individuals with IGHV mutated CLL); or
- Fludarabine and rituximab (FR) regimen [not recommended for CLL with del(11q)]; or
Second-line and subsequent therapy for CLL/SLL without del(17p)/TP53 mutation in frail individuals with significant comorbidity or age greater than or equal to 65 years and younger individuals with significant comorbidities (creatining clearance less than 70 mL/min) who have indications for retreatment:
- In combination with idelalisib or venetoclax; or
- As a single agent in a dose-dense regimen; or
- In combination with alemtuzumab, chlorambucil. lenalidomide, or high-dose methylprednisolone; or
- As a component of reduced-dose FCR (fludarabine, cyclophosphamide, and rituximab) or reduced-dose PCR (pentostatin, cyclophosphamide, and rituximab) regimen; or
Second-line and subsequent therapy in combination with bendamustine and with or without ibrutinib or idelalisib for CLL/SLL without del(17p)/TP53 mutation in individuals greater than or equal to 65 years of age or younger individuals with significant comorbidities (CrCl less than 70 ml/min) who have indications for retreatment (not recommended for frail individuals); or
Second-line and subsequent therapy for CLL/SLL without del(17p)/TP53 mutation in individuals less than 65 years without significant comorbidities who have indications for retreatment:
- In combination with idelalisib or venetoclax; or
- In combination with alemtuzumab, bendamustine with or without ibrutinib or idelalisib, high-dose methylprednisolone, or lenalidomide; or
- As a component of FCR (fludarabine, cyclophosphamide, and rituximab) or PCR (pentostatin, cyclophosphamide, and rituximab) regimen; or
Second-line and subsequent therapy for CLL/SLL with del(17p)/TP53 in individuals with indications for retreatment in combination with:
- Idelalisib or venetoclax; or
- Alemtuzumab, lenalidomide, or high-dose methylprednisolone; or
Initial therapy for histologic (Richter's) transformation to DLBCL (clonally related or unknown clonal status) as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) with rituximab regimen; or
- HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab regimen alternating with high-dose methotrexate and cytarabine regimen; or
- OFAR (oxaliplatin, fludarabine, cytarabine, and rituximab) regimen; or

Hairy Cell Leukemia

Used in individuals with indications for treatment in combination with:
- Cladribine as initial therapy; or
- Cladribine for less than complete response or relapse within two (2) years of complete response following initial treatment with pentostatin; or
- Pentostatin for less than complete response or relapse within two (2) years of complete response following initial treatment with cladribine; or
- Cladribine or pentostatin for relapse greater than or equal to two (2) years following initial treatment; or
- Vemurafenib for progression after therapy for relapsed/refractory disease; or
As a single agent in individuals with indications for treatment who are unable to receive purine analogs for:
- Less than complete response following initial treatment with cladribine or pentostatin; or
- Relapse; or

Hematopoietic Cell Transplantation

For chronic graft-versus-host disease (GVHD) as additional therapy in conjunction with systemic corticosteroids following no response (steroid refractory disease) to first-line therapy options; or

Hodgkin Lymphoma - Nodular Lymphocyte-Predominant

Primary treatment as a component of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) + rituximab, CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + rituximab, or CVP (cyclophosphamide, vinblastine, prednisolone) + rituximab for individuals 18 years of age or older:

- With involved site radiation therapy (ISRT) for stage IA or IIA disease (bulky or non-contiguous); or
- With ISRT for stage IB or IIB disease; or
- With or without ISRT for stage III-IV disease; or

Primary treatment as a single agent for stage III or IV disease; or
Second-line or subsequent systemic therapy (if not previously used) for progressive, relapsed, or refractory disease as a single agent, with or without ISRT; or
May be considered as maintenance therapy for individuals treated with second-line systemic therapy with rituximab alone for progressive, relapsed, or refractory disease; or
Second-line or subsequent systemic therapy (if not previously used) for progressive, relapsed, or refractory disease in combination with:
- DHAP (dexamethasone, cisplatin, and high-dose cytarabine); or
- ESHAP (etoposide, methylprednisolone, high-dose cytarabine, and cisplatin); or
- ICE (ifosfamide, carboplatin, and etoposide); or
- IGEV (ifosfamide, gemcitabine, and vinorelbine); or
- Bendamustine; or
- ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) + rituximab; or
- CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + rituximab; or
- CVP (cyclophosphamide, vinblastine, prednisolone) + rituximab; or

Immune Checkpoint Inhibitor-Related Toxicities

Management of the following immunotherapy-related toxicities:
- As additional therapy for moderate (G2), severe (G3) or life-threatening (G4) immunotherapy-related bullous dermatitis; or
- Moderate, severe, or life-threatening steroid-refractory myalgias or myositis; or
- For severe (G 3-4) myasthenia gravis in individuals refractory to plasmapheresis or intravenous immune globulin (IVIG)
- Treatment of immunotherapy-related encephalitis after viral causes have been excluded in individuals positive for autoimmune encephalopathy antibody, or who have had limited or no improvement after 7-14 days on pulse-dose methylprednisolone with or without IVIG; or

Rosai-Dorfman Disease

First-line or subsequent therapy, irrespective of mutation for nodal and immune-cytopenia diseases, as a single agent for:
- Symptomatic unresectable (bulky/site of disease) unifocal disease; or
- Symptomatic multifocal disease; or
- Relapsed/refractory disease; or
- Immunoglobulin G4 (IgG4) disease; or

Splenic Marginal Zone Lymphoma

Therapy as a single-agent for symptomatic individuals with splenomegaly who are:
- Hepatitis C negative; or
- Hepatitis C positive with contraindications for hepatitis treatment; or
- Hepatitis C positive with no response to appropriate hepatitis treatment; or
Used as a single agent or in combination with chlorambucil or cyclophosphamide for disease recurrence following initial management of splenomegaly in elderly or infirm individuals with indications for treatment when tolerability of combination chemotherapy is a concern as:
- First-line therapy (if treatment naive); or
- Second-line or subsequent therapy; or
First-line therapy for disease recurrence following initial management of splenomegaly in treatment naive individuals with indications for treatment as a single agent, in combination with bendamustine, or as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
Used in combination with lenalidomide as first-line therapy for disease recurrence following initial treatment for splenomegaly in treatment naive individuals with indications for treatment; or
Consolidation as optional first-line extended therapy in individuals initially treated with single agent rituximab; or
Second-line (if prior treatment with rituximab) or subsequent therapy for disease recurrence in individuals with indications for treatment in combination with bendamustine (not recommended if previously treated with bendamustine**) , or as a component of:
- RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen; or
- RCVP (rituximab, cyclophosphamide, vincristine, and prednisone) regimen; or
Second-line (if previously treated with rituximab) or subsequent therapy in combination with lenalidomide for disease recurrence in individuals with indications for treatment, including the elderly or infirm when tolerability of combination chemotherapy is a concern; or
Second-line or subsequent therapy as a single agent for disease recurrence in individuals with indications for treatment (if previously treated with rituximab with a longer duration of remission); or

Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma

Used as a component of CaRD (carfilzomib, rituximab, and dexamethasone) regimen or in combination with ixazomib and dexamethasone:
- As primary therapy; or
- For relapse if previously used as primary therapy that was well tolerated and elicited a prolonged response; or
Used as primary therapy, for relapse if previously used as primary therapy that was well tolerated and elicited a prolonged response, or for progressive or relapsed disease:
- In combination with bendamustine; or
- In combination with bortezomib and dexamethasone; or
- In combination with ibrutinib; or
- In combination with cyclophosphamide and dexamethasone; or
- As a single agent; or
- In combination with bortezomib; or
- In combination with cyclophosphamide and prednisone; or
- As a component of CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) regimen; or
- In combination with cladribine or fludarabine in individuals who are not potential autologous stem cell transplant candidates; or
- As a component of FCR (fludarabine, cyclophosphamide, and rituximab) regimen in individuals who are not potential autologous stem cell transplant candidates; or
Consider for maintenance therapy following a complete, very good partial, partial, or minor response to primary therapy if regimen included rituximab.

Procedure Codes

J9312

Rituximab and hyaluronidase human (Rituxan Hycela^(R)) subcutaneous (SC) - healthcare administered

FDA Approved Indications

Chronic lymphoid leukemia (CLL)

Previously untreated and previously treated CLL in combination with fludarabine and cyclophosphamide (FC); or

Diffuse Large B-Cell Lymphoma (DLBCL)

Previously untreated DLBCL in combination with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or other anthracycline-based chemotherapy regimens; or

Follicular lymphoma (FL)

Relapsed or refractory, follicular lymphoma as a single agent; or
Previously untreated follicular lymphoma in combination with first line chemotherapy and, in individuals achieving a complete or partial response to rituximab (Rituxan) in combination with chemotherapy, as single-agent maintenance therapy; or
Non-progressing (including stable disease), follicular lymphoma as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or

NCCN Approved Recommendations

Castleman's Disease; or
DLBCL; or
Follicular Lymphoma (grade 1-2); or
Gastric MALT; or
High-Grade B-Cell Lymphomas; or
Histologic Transformation of Nodal Marginal Zone Lymphoma to DLBCL; or
High-Grade B-Cell Lymphomas with Translocations of MYC and BCL2 and/or BCL6 (Double/Triple Hit Lymphoma; or
Mantle Cell Lymphoma; or
Nodal Marginal Zone Lymphoma; or
Nongastric MALT Lymphoma (Noncutaneous); or
Post-Transplant Lymphoproliferative Disorders; or
Splenic Marginal Zone Lymphoma; or
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma; or
Hairy Cell Leukemia; or
Primary Cutaneous B-Cell Lymphomas or follicle center lymphoma with:
- Solitary/regional, T1-2 disease that is refractory to initial therapy; or
- Generalized disease (skin only), T3; or
Waldenström Macroglobulinemia / Lymphoplasmacytic Lymphoma.

Individuals receiving rituximab and hyaluronidase human (Rituxan Hycela) cannot have a live vaccination prior to or during treatment with rituximab and hyaluronidase human (Rituxan Hycela).

Procedure Codes

J9311

Rituximab-abbs (Truxima) may be considered medically necessary for the treatment of individuals 18 years and older for ANY of the following indications:

FDA Indications

Chronic Lymphocytic Leukemia (CLL)

For previously untreated or previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide; or

Granulomatosis with Polyangitis, Wegener's Granulomatosis, and Microscopic Polyangiitis

As therapy in combination with glucocorticoids; or

Non-Hodgkin's Lymphoma (NHL)

Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent; or
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in individuals achieving a complete or partial response to a rituximab product in combination with chemotherapy, as a single agent maintenance therapy; or
Non-progressive (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or
Previously untreated DLBCL, CD20-positive NHL in combination with CHOP or anthracycline-based chemotherapy regimens; or

Rheumatoid Arthritis (RA)

As therapy in combination with methotrexate, or other conventional synthetic DMARD if methotrexate is contraindicated, for moderately-to-severely-active RA who have had an inadequate response to one or more TNF antagonist therapies:
- Combination therapy with methotrexate or other conventional synthetic DMARD not applicable to individuals who have had an inadequate response to methotrexate or other conventional synthetic DMARDs; or

NCCN Recommendations

As a substitute for rituximab (Rituxan) for the treatment of ANY of the following where rituximab (Rituxan) was recommended:

AIDS-related B-cell lymphoma; or
Burkitt lymphoma; or
Castleman's disease; or
Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); or
DLBCL; or
Follicular lymphoma (grade 1-2); or
Gastric MALT lymphoma; or
Hairy cell leukemia; or
Hematopoietic Cell Transplantation; or
High-grade B-cell lymphomas; or
High-grade-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma); or
Histologic transformation of nodal marginal zone lymphoma to DLBCL; or
Mantle cell lymphoma; or
Management of immunotherapy-related toxicities-immune checkpoint inhibitor-related toxicities; or
Nodal marginal zone lymphoma; or
Nongastric MALT lymphoma (noncutaneous); or
Post-transplant lymphoproliferative disorders; or
Primary cutaneous B-cell lymphoma; or
Rosai-Dorfman disease; or
Splenic marginal zone lymphoma.

Procedure Codes

Q5115

Rituximab-pvvr (Ruxience) or rituximab-arrx (Riabni) may be considered medically necessary for the treatment of individuals 18 years and older for ANY of the following indications:

FDA Indications

Chronic Lymphocytic Leukemia (CLL)

For previously untreated or previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide; or

Granulomatosis with Polyangitis, Wegener's Granulomatosis, and Microscopic Polyangiitis

As therapy in combination with glucocorticoids; or

Non-Hodgkin's Lymphoma (NHL)

Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent; or
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in individuals achieving a complete or partial response to a rituximab product in combination with chemotherapy, as a single agent maintenance therapy; or
Non-progressive (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy; or
Previously untreated DLBCL, CD20-positive NHL in combination with CHOP or anthracycline-based chemotherapy regimens; or

NCCN Recommendations

As a substitute for rituximab (Rituxan) for the treatment of ANY of the following where rituximab (Rituxan) was recommended:

AIDS-related B-cell lymphoma; or
Burkitt lymphoma; or
Castleman's disease; or
Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); or
DLBCL; or
Follicular lymphoma (grade 1-2); or
Hairy cell leukemia; or
Hematopoietic Cell Transplantation; or
High-grade B-cell lymphomas; or
High-grade-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double/triple hit lymphoma); or
Histologic transformation of nodal marginal zone lymphoma to DLBCL; or
Mantle cell lymphoma; or
Management of immunotherapy-related toxicities-immune checkpoint inhibitor-related toxicities; or
Nodal marginal zone lymphoma; or
Nongastric MALT lymphoma (noncutaneous); or
Post-transplant lymphoproliferative disorders; or
Primary cutaneous B-cell lymphoma; or
Rosai-Dorfman disease; or
Splenic marginal zone lymphoma.

Procedure Codes

Q5119

Q5123

**Note: Language derived from National Comprehensive Cancer Network (NCCN) guidelines

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J9312

C79.32	C81.00	C81.01	C81.02	C81.03	C81.04	C81.05
C81.06	C81.07	C81.08	C81.09	C82.00	C82.01	C82.02
C82.03	C82.04	C82.05	C82.06	C82.07	C82.08	C82.09
C82.10	C82.11	C82.12	C82.13	C82.14	C82.15	C82.16
C82.17	C82.18	C82.19	C82.20	C82.21	C82.22	C82.23
C82.24	C82.25	C82.26	C82.27	C82.28	C82.29	C82.30
C82.31	C82.32	C82.33	C82.34	C82.35	C82.36	C82.37
C82.38	C82.39	C82.40	C82.41	C82.42	C82.43	C82.44
C82.45	C82.46	C82.47	C82.48	C82.49	C82.50	C82.51
C82.52	C82.53	C82.54	C82.55	C82.56	C82.57	C82.58
C82.59	C82.60	C82.61	C82.62	C82.63	C82.64	C82.65
C82.66	C82.67	C82.68	C82.69	C82.80	C82.81	C82.82
C82.83	C82.84	C82.85	C82.86	C82.87	C82.88	C82.89
C82.90	C82.91	C82.92	C82.93	C82.94	C82.95	C82.96
C82.97	C82.98	C82.99	C83.00	C83.01	C83.02	C83.03
C83.04	C83.05	C83.06	C83.07	C83.08	C83.09	C83.10
C83.11	C83.12	C83.13	C83.14	C83.15	C83.16	C83.17
C83.18	C83.19	C83.30	C83.31	C83.32	C83.33	C83.34
C83.35	C83.36	C83.37	C83.38	C83.39	C83.50	C83.51
C83.52	C83.53	C83.54	C83.55	C83.56	C83.57	C83.58
C83.59	C83.70	C83.71	C83.72	C83.73	C83.74	C83.75
C83.76	C83.77	C83.78	C83.79	C83.80	C83.81	C83.82
C83.83	C83.84	C83.85	C83.86	C83.87	C83.88	C83.89
C83.90	C83.91	C83.92	C83.93	C83.94	C83.95	C83.96
C83.97	C83.98	C83.99	C85.10	C85.11	C85.12	C85.13
C85.14	C85.15	C85.16	C85.17	C85.18	C85.19	C85.20
C85.21	C85.22	C85.23	C85.24	C85.25	C85.26	C85.27
C85.28	C85.29	C85.80	C85.81	C85.82	C85.83	C85.84
C85.85	C85.86	C85.87	C85.88	C85.89	C88.0	C88.4
C91.00	C91.01	C91.02	C91.10	C91.12	C91.40	C91.42
D36.0	D47.Z1	D47.Z2	D59.0	D59.10	D59.11	D59.12
D59.13	D59.19	D66	D69.3	D69.41	D69.42	D69.49
D89.811	D89.812	D89.813	G04.81	G35	G36.0	G37.0
G37.5	G60.8	G61.89	G62.89	G64	G70.00	G70.01
L10.0	L10.1	L10.2	L10.3	L10.4	L10.5	L10.81
L10.89	L12.0	L12.1	L12.2	L12.31	L12.35	L12.8
L13.8	L13.9	M05.011	M05.012	M05.021	M05.022	M05.031
M05.032	M05.041	M05.042	M05.051	M05.052	M05.061	M05.062
M05.071	M05.072	M05.09	M05.111	M05.112	M05.121	M05.122
M05.131	M05.132	M05.141	M05.142	M05.151	M05.152	M05.161
M05.162	M05.171	M05.172	M05.19	M05.211	M05.212	M05.221
M05.222	M05.231	M05.232	M05.241	M05.242	M05.251	M05.252
M05.261	M05.262	M05.271	M05.272	M05.29	M05.311	M05.312
M05.321	M05.322	M05.331	M05.332	M05.341	M05.342	M05.351
M05.352	M05.361	M05.362	M05.371	M05.372	M05.39	M05.411
M05.412	M05.421	M05.422	M05.431	M05.432	M05.441	M05.442
M05.451	M05.452	M05.461	M05.462	M05.471	M05.472	M05.49
M05.511	M05.512	M05.521	M05.522	M05.531	M05.532	M05.541
M05.542	M05.551	M05.552	M05.561	M05.562	M05.571	M05.572
M05.59	M05.611	M05.612	M05.621	M05.622	M05.631	M05.632
M05.641	M05.642	M05.651	M05.652	M05.661	M05.662	M05.671
M05.672	M05.69	M05.711	M05.712	M05.721	M05.722	M05.731
M05.732	M05.741	M05.742	M05.751	M05.752	M05.761	M05.762
M05.771	M05.772	M05.79	M05.811	M05.812	M05.821	M05.822
M05.831	M05.832	M05.841	M05.842	M05.851	M05.852	M05.861
M05.862	M05.871	M05.872	M05.89	M05.9	M06.011	M06.012
M06.021	M06.022	M06.031	M06.032	M06.041	M06.042	M06.051
M06.052	M06.061	M06.062	M06.071	M06.072	M06.08	M06.09
M06.1	M06.211	M06.212	M06.221	M06.222	M06.231	M06.232
M06.241	M06.242	M06.251	M06.252	M06.262	M06.271	M06.272
M06.28	M06.29	M06.311	M06.312	M06.321	M06.322	M06.331
M06.332	M06.341	M06.342	M06.351	M06.352	M06.361	M06.362
M06.371	M06.372	M06.38	M06.39	M06.811	M06.812	M06.821
M06.822	M06.831	M06.832	M06.841	M06.842	M06.851	M06.852
M06.861	M06.862	M06.871	M06.872	M06.88	M06.89	M06.9
M30.0	M30.1	M30.2	M30.8	M31.1	M31.30	M31.31
M31.7	M32.0	M32.10	M32.11	M32.12	M32.13	M32.14
M32.15	M32.19	M32.8	M32.9	M33.20	M33.21	M33.22
M33.29	M33.90	M33.91	M33.92	M33.93	M33.99	M34.0
M34.1	M34.2	M34.81	M34.82	M34.83	M34.9	M35.00
M35.01	M35.02	M35.03	M35.04	M35.09	N01.0	N01.1
N01.2	N02.0	N02.1	N02.2	N02.3	N02.5	N02.8
N02.9	N03.0	N03.2	N04.0	N04.1	N04.2	N04.3
N04.4	N04.5	N04.6	N04.7	N04.8	N04.9	N05.0
N05.2	N07.0	N07.1	N07.2	N08	R59.0	R59.1
R59.9	T86.09	Z85.71	Z85.72	Z85.79	Z94.81

Covered Diagnosis Codes for Procedure Code J9311

C82.00	C82.01	C82.02	C82.03	C82.04	C82.05	C82.06
C82.07	C82.08	C82.09	C82.10	C82.11	C82.12	C82.13
C82.14	C82.15	C82.16	C82.17	C82.18	C82.19	C82.20
C82.21	C82.22	C82.23	C82.24	C82.25	C82.26	C82.27
C82.28	C82.29	C82.30	C82.31	C82.32	C82.33	C82.34
C82.35	C82.36	C82.37	C82.38	C82.39	C82.40	C82.41
C82.42	C82.43	C82.44	C82.45	C82.46	C82.47	C82.48
C82.49	C82.50	C82.51	C82.52	C82.53	C82.54	C82.55
C82.56	C82.57	C82.58	C82.59	C82.60	C82.61	C82.62
C82.63	C82.64	C82.65	C82.66	C82.67	C82.68	C82.69
C82.80	C82.81	C82.82	C82.83	C82.84	C82.85	C82.86
C82.87	C82.88	C82.89	C82.90	C82.91	C82.92	C82.93
C82.94	C82.95	C82.96	C82.97	C82.98	C82.99	C83.00
C83.01	C83.02	C83.03	C83.04	C83.05	C83.06	C83.07
C83.08	C83.09	C83.10	C83.11	C83.12	C83.13	C83.14
C83.15	C83.16	C83.17	C83.18	C83.19	C83.30	C83.31
C83.32	C83.33	C83.34	C83.35	C83.36	C83.37	C83.38
C83.39	C83.80	C83.81	C83.82	C83.83	C83.84	C83.85
C83.86	C83.87	C83.88	C83.89	C85.20	C85.21	C85.22
C85.23	C85.24	C85.25	C85.26	C85.27	C85.28	C85.29
C85.80	C85.81	C85.82	C85.83	C85.84	C85.85	C85.86
C85.87	C85.88	C85.89	C88.4	C91.10	C91.12	C91.40
C91.42	D36.0	D47.Z1	D47.Z2	R59.0	R59.1	R59.9

Covered Diagnosis Codes for Q5115

C82.00	C82.01	C82.02	C82.03	C82.04	C82.05	C82.06
C82.07	C82.08	C82.09	C82.10	C82.11	C82.12	C82.13
C82.14	C82.15	C82.16	C82.17	C82.18	C82.19	C82.20
C82.21	C82.22	C82.23	C82.24	C82.25	C82.26	C82.27
C82.28	C82.29	C82.30	C82.31	C82.32	C82.33	C82.34
C82.35	C82.36	C82.37	C82.38	C82.39	C82.40	C82.41
C82.42	C82.43	C82.44	C82.45	C82.46	C82.47	C82.48
C82.49	C82.50	C82.51	C82.52	C82.53	C82.54	C82.55
C82.56	C82.57	C82.58	C82.59	C82.60	C82.61	C82.62
C82.63	C82.64	C82.65	C82.66	C82.67	C82.68	C82.69
C82.80	C82.81	C82.82	C82.83	C82.84	C82.85	C82.86
C82.87	C82.88	C82.89	C82.90	C82.91	C82.92	C82.93
C82.94	C82.95	C82.96	C82.97	C82.98	C82.99	C83.00
C83.01	C83.02	C83.03	C83.04	C83.05	C83.06	C83.07
C83.08	C83.09	C83.10	C83.11	C83.12	C83.13	C83.14
C83.15	C83.16	C83.17	C83.18	C83.19	C83.30	C83.31
C83.32	C83.33	C83.34	C83.35	C83.36	C83.37	C83.38
C83.39	C83.70	C83.71	C83.72	C83.73	C83.74	C83.75
C83.76	C83.77	C83.78	C83.79	C83.80	C83.81	C83.82
C83.83	C83.84	C83.85	C83.86	C83.87	C83.88	C83.89
C83.90	C83.91	C83.92	C83.93	C83.94	C83.95	C83.96
C83.97	C83.98	C83.99	C85.10	C85.11	C85.12	C85.13
C85.14	C85.15	C85.16	C85.17	C85.18	C85.19	C85.20
C85.21	C85.22	C85.23	C85.24	C85.25	C85.26	C85.27
C85.28	C85.29	C85.80	C85.81	C85.82	C85.83	C85.84
C85.85	C85.86	C85.87	C85.88	C85.89	C88.4	C91.10
C91.40	C91.42	D36.0	D47.Z1	D47.Z2	M05.011	M05.012
M05.021	M05.022	M05.031	M05.032	M05.041	M05.042	M05.051
M05.052	M05.061	M05.062	M05.071	M05.072	M05.09	M05.111
M05.112	M05.121	M05.122	M05.131	M05.132	M05.141	M05.142
M05.151	M05.152	M05.161	M05.162	M05.171	M05.172	M05.19
M05.211	M05.212	M05.221	M05.222	M05.231	M05.232	M05.241
M05.242	M05.251	M05.252	M05.261	M05.262	M05.271	M05.272
M05.29	M05.311	M05.312	M05.321	M05.322	M05.331	M05.332
M05.341	M05.342	M05.351	M05.352	M05.361	M05.362	M05.371
M05.372	M05.39	M05.411	M05.412	M05.421	M05.422	M05.431
M05.432	M05.441	M05.442	M05.451	M05.452	M05.461	M05.462
M05.471	M05.472	M05.49	M05.511	M05.512	M05.521	M05.522
M05.531	M05.532	M05.541	M05.542	M05.551	M05.552	M05.561
M05.562	M05.571	M05.572	M05.59	M05.611	M05.612	M05.621
M05.622	M05.631	M05.632	M05.641	M05.642	M05.651	M05.652
M05.661	M05.662	M05.671	M05.672	M05.69	M05.711	M05.712
M05.721	M05.722	M05.731	M05.732	M05.741	M05.742	M05.751
M05.752	M05.761	M05.762	M05.771	M05.772	M05.79	M05.811
M05.812	M05.821	M05.822	M05.831	M05.832	M05.841	M05.842
M05.851	M05.852	M05.861	M05.862	M05.871	M05.872	M05.89
M05.9	M06.011	M06.012	M06.021	M06.022	M06.031	M06.032
M06.041	M06.042	M06.051	M06.052	M06.061	M06.062	M06.071
M06.072	M06.08	M06.09	M06.1	M06.211	M06.212	M06.221
M06.222	M06.231	M06.232	M06.241	M06.242	M06.251	M06.252
M06.262	M06.271	M06.272	M06.28	M06.29	M06.311	M06.312
M06.321	M06.322	M06.331	M06.332	M06.341	M06.342	M06.351
M06.352	M06.361	M06.362	M06.371	M06.372	M06.38	M06.39
M06.811	M06.812	M06.821	M06.822	M06.831	M06.832	M06.841
M06.842	M06.851	M06.852	M06.861	M06.862	M06.871	M06.872
M06.88	M06.89	M06.9	M31.30	M31.31	M31.7	R59.0
R59.1	R59.9

Covered Diagnosis Codes for Q5119 and Q5123

C82.00	C82.01	C82.02	C82.03	C82.04	C82.05	C82.06
C82.07	C82.08	C82.09	C82.10	C82.11	C82.12	C82.13
C82.14	C82.15	C82.16	C82.17	C82.18	C82.19	C82.20
C82.21	C82.22	C82.23	C82.24	C82.25	C82.26	C82.27
C82.28	C82.29	C82.30	C82.31	C82.32	C82.33	C82.34
C82.35	C82.36	C82.37	C82.38	C82.39	C82.40	C82.41
C82.42	C82.43	C82.44	C82.45	C82.46	C82.47	C82.48
C82.49	C82.50	C82.51	C82.52	C82.53	C82.54	C82.55
C82.56	C82.57	C82.58	C82.59	C82.60	C82.61	C82.62
C82.63	C82.64	C82.65	C82.66	C82.67	C82.68	C82.69
C82.80	C82.81	C82.82	C82.83	C82.84	C82.85	C82.86
C82.87	C82.88	C82.89	C82.90	C82.91	C82.92	C82.93
C82.94	C82.95	C82.96	C82.97	C82.98	C82.99	C83.00
C83.01	C83.02	C83.03	C83.04	C83.05	C83.06	C83.07
C83.08	C83.09	C83.10	C83.11	C83.12	C83.13	C83.14
C83.15	C83.16	C83.17	C83.18	C83.19	C83.30	C83.31
C83.32	C83.33	C83.34	C83.35	C83.36	C83.37	C83.38
C83.39	C83.70	C83.71	C83.72	C83.73	C83.74	C83.75
C83.76	C83.77	C83.78	C83.79	C83.80	C83.81	C83.82
C83.83	C83.84	C83.85	C83.86	C83.87	C83.88	C83.89
C83.90	C83.91	C83.92	C83.93	C83.94	C83.95	C83.96
C83.97	C83.98	C83.99	C85.10	C85.11	C85.12	C85.13
C85.14	C85.15	C85.16	C85.17	C85.18	C85.19	C85.20
C85.21	C85.22	C85.23	C85.24	C85.25	C85.26	C85.27
C85.28	C85.29	C85.80	C85.81	C85.82	C85.83	C85.84
C85.85	C85.86	C85.87	C85.88	C85.89	C88.4	C91.10
C91.40	C91.42	D36.0	D47.Z1	D47.Z2	M31.30	M31.31
M31.7	R59.0	R59.1	R59.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020Added rituximab-pvvr (Ruxience) for 18 years and older, added additional FDA indications and NCCN recommendations for biosimilar products

Internal Medical Policy Committee 5-19-2020 Added additional indication to TTP criteria

Internal Medical Policy Committee 7-22-2020 Added new code, Q5119 for rituximab-pvvr (Ruxience)

Internal Medical Policy Committee 9-21-2020 Updated criteria and diagnosis codes, separated criteria and diagnosis codes for Truxima and Ruxience

Internal Medical Policy Committee 3-17-2021 Added rituximab-arrx (Riabni) to policy and updated NCCN recommendations for rituximab-abbs (Truxima) and rituximab-pvvr (Ruxience)

Internal Medical Policy Committee 7-22-2021 Added new code, Q5123 for rituximab-arrx (Riabni) to policy effective 7-1-2021, updated NCCN recommendations

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