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.
Tremelimumab (Imjudo) may be considered medically necessary for ANY of the following conditions:
Hepatocellular Carcinoma (HCC)
- In combination with durvalumab, for the treatment of adult individuals 18 years of age or older with unresectable HCC; or
Non-Small Cell Lung Cancer (NSCLC)
- In combination with durvalumab and platinum-based chemotherapy, for the treatment of adult individuals 18 years of age or older with metastatic NSCLC with no sensitizing EGFR or ALK mutations; or
Compendia Sources
Tremelimumab (Imjudo) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of tremelimumab (Imjudo) 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.
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
C15.3
|
C15.4
|
C15.5
|
C15.8
|
C15.9
|
C16.1
|
C16.2
|
C16.3
|
C16.4
|
C16.5
|
C16.6
|
C16.8
|
C16.9
|
C22.0
|
C22.8
|
C22.9
|
C33
|
C34.00
|
C34.01
|
C34.02
|
C34.10
|
C34.11
|
C34.12
|
C34.2
|
C34.30
|
C34.31
|
C34.32
|
C34.80
|
C34.81
|
C34.82
|
C34.90
|
C34.91
|
C34.92
|
D37.1
|
D37.8
|
D37.9
|
Professional Statements and Societal Positions Guidelines
Not Applicable
ND Committee Review
Internal Medical Policy Committee 11-19-2024 Effective December 09, 2024
- Adopted Medicaid Expansion specific policy
