Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Tarlatamab-dlle (Imdelltra) may be considered medically necessary in individuals 18 years and older for the following:
-
Individual is diagnosed with extensive-stage small cell lung cancer (ES-SCLC);
and
-
Individual has disease progression on or after platinum-based chemotherapy;
or
Compendia Sources
Tarlatamab-dlle (Imdelltra) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
Note:
Administration of the step-up dosing schedule should be performed in an appropriate healthcare setting with medical support to manage severe reactions.
The use of tarlatamab-dlle (Imdelltra) 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 Codes
