Criteria
Coverage is subject to the specific terms of the member's benefit plan.
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, 2A, or 2B 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
