Siltuximab (Sylvant) (ARCHIVED)

Policy ID: I-170-008

Section: Injections

Effective Date: February 01, 2020

Revised Date: October 25, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Applies To: Commercial Only

**This policy has been Archived effective December 08, 2024. Click the Archive tab above for more information.**

Policy ID: I-170-008

Section: Injections

Effective Date: February 01, 2020

Revised Date: October 25, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Archived Date: December 08, 2024

Applies To: Commercial Only

Description

Siltuximab (Sylvant®) is an interleukin-6 (IL-6) antagonist . It binds to human IL-6 and prevents the binding of IL-6 to both soluble and membrane-bound IL-6 receptors. IL-6 has been shown to be involved in diverse normal and physiologic processes such as induction of immunoglobulin secretion. Overproduction of IL-6 has been linked to systemic manifestations of multi-centric Castleman's Disease (CD).

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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.

Siltuximab (Sylvant) may be considered medically necessary for individuals 18 years of age or older when ALL of the following criteria are met:

Treatment of individual with multi-centric Castleman's disease (CD) who is human immunodeficiency virus-negative and human herpesvirus-8 (HHV-8)-negative; and
Individual does not have organ failure; and
No concurrent clinically significant infection (for example, Hepatitis B or C); and
No concurrent lymphoma; or

Compendia Sources

Siltuximab (Sylvant) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations

The use of siltuximab (Sylvant) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J2860

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. 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

D47.Z2

D89.831

D89.832

D89.833

D89.834

D89.839

G92.00

G92.01

G92.02

G92.03

G92.04

T80.82XA

T80.82XS

T80.89XA

T80.89XS

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Adopt new pre-certification policy

Internal Medical Policy Committee 11-19-2020

Updated Description, and
Updated minor wording changes,
no clinical content change

Internal Medical Policy Committee 11-23-2021 Annual review, no clinical content change

Internal Medical Policy Committee 5-24-2022

Removed NCCN recommendations and
Added this statement 'Siltuximab (Sylvant) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.',
Updated the experimental/investigational statement,
Updated dx codes

Internal Medical Policy Committee 5-23-2023 - Effective July 1, 2023

Added diagnosis codes G92.00, G92.01, G92.02, G92.03, G92.04, T80.82XA, T80.82XS and T80.89XA
Updated E/I statement

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Annual review no clinical content change

Internal Medical Policy Committee 11-19-2024 Effective December 08, 2024

Archived policy

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.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search