Trastuzumab (Herceptin) and trastuzumab biosimilars (Hercessi, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) may be considered medically necessary for
ANY
of the following indications:
Breast Cancer
- For adjuvant treatment of HER2-overexpressing node positive or node negative (estrogen receptor/progesterone [ER/PR] receptor negative or with one high risk feature) breast cancer in ANY of the following:
-
As part of a treatment regimen consisting of doxorubicin, cyclophosphamide, and either paclitaxel or docetaxel;
or
-
As part of a treatment regimen with docetaxel and carboplatin;
or
-
As a single agent following multi-modality anthracycline based therapy;
or
-
For metastatic breast cancer in
ANY
of the following:
-
In combination with paclitaxel for first-line treatment of HER2-ovrexpressing metastatic breast cancer;
or
-
As a single agent for treatment of HER2-overexpressing breast cancer in individuals who have received one or more chemotherapy regimens for metastatic disease;
or
Metastatic Gastric or Gastroesophageal Junction Adenocarcinoma
- For treatment of HER2-overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma in combination with cisplatin and capecitabine or 5-fluorouracil in individuals who have not received prior treatment for metastatic disease.
Compendia Sources
Trastuzumab (Herceptin) and trastuzumab biosimilars (Hercessi, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of trastuzumab (Herceptin) and trastuzumab biosimilars (Hercessi, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
| J9355 | Q5112 | Q5113 | Q5114 | Q5116 | Q5117 | J9999 |
