Criteria
Coverage is subject to the specific terms of the member's benefit plan.
The use of tagraxofusp-erzs (Elzonris) for the treatment (e.g., first-line therapy, as treatment induction, continuation after induction, or for relapsed/refractory disease if not already used) of BPDCN may be considered medically necessary when
ALL
of the following criteria are met:
-
Documentation of diagnosis of BPDCN;
and
-
Medication prescribed by or in consultation with an oncologist or hematologist;
and
-
Individual is two (2) years of age or older;
and
-
Initial treatment cycle
MUST
be administered in an inpatient setting and individual will be monitored for at least 24 hours after last infusion:
-
Subsequent treatment cycles can be administered in appropriate outpatient setting;
or
Compendia Sources
Tagraxofusp-erzs (Elzonris) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of tagraxofusp-erzs (Elzonris) 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
