CAM 150

TECENTRIQ™ (atezolizumab)

Category:Prescription Drug   Last Reviewed:June 2019
Department(s):Medical Affairs   Next Review:June 2020
Original Date:June 2016    

Policy
Tecentriq (atezolizumab) is considered MEDICALLY NECESSARY for members with locally advanced or metatstatic urothelial carcinoma who meet at least one of the two following criteria:

  • Have disease progression during or following platinum-containing chemotherapy 
  • Have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy  

Tecentriq™ (atezolizumab) is considered MEDICALLY NECESSARY for members with metastatic non-small cell lung cancer who have disease progression during or following platinum-containing chemotherapy.  Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA- approved therapy for these aberrations prior to receiving Tecentriq. 

Tecentriq™ is considered MEDICALLY NECESSARY in combination with paclitaxel protein-bound for the treatment of adult patients with unresectable locally advanced or metastatic TNBC whose tumors express PD-L1 (PD-L1 stained tumor-infiltrating immune cells (IC) of any intensity covering > 1% of the tumor area), as determined by an FDA-approved test. 

Tecentriq™ is considered MEDICALLY NECESSARY in combination with carboplatin and etoposide, for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC).

Dosage 

  • Administer 1,200 mg as an intravenous infusion over 60 minutes every 3 weeks. (2.1)
  • Dilute prior to intravenous infusion. (2.3) 

Injection: 1,200 mg/20 mL (60 mg/mL) solution in a single-dose vial (3)

Use of Tecentriq for any use other than described above is considered INVESTIGATIONAL.

References 

  1. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm501762.htm.  FDA approves new, targeted treatment for bladder cancer.
  2. http://www.gene.com/media/press-releases/14621/2016-03-14/fda-grants-genentechs-cancer-immunothera. FDA Grants Genentech’s Cancer Immunotherapy Atezolizumab Priority Review for Advanced Bladder Cancer.
  3. Atezolizumab (Tecentriq™) prescribing information, 2016 available at: http://www.gene.com/download/pdf/tecentriq_prescribing.pdf

Coding Section

Codes Number Description
CPT 96413

Chemo administration, IV infusion technique; up to 1 hour, single or initial substance/drug

  96415 each additional hour
  96416 Initiation of prolonged chemo infusion (more than 8 hrs), requiring use of a portable or implantable pump
  96417 each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)
HCPCS  C9483 (effective 10/1/16)  Injection, atezolizumab Injection, atezolizumab, 10 mg 
  J3490 Unclassified Drugs
  J9022 (effective 1/1/2018)  Injection, atezolizumab, 10 mg 
ICD10 C67.0 Malignant neoplasm of trigone of bladder
  C67.1 Malignant neoplasm of dome of bladder
  C67.2 Malignant neoplasm of lateral wall of bladder
  C67.3 Malignant neoplasm of anterior wall of bladder
  C67.4 Malignant neoplasm of posterior wall of bladder
  C67.5 Malignant neoplasm of bladder neck
  C67.6 Malignant neoplasm of ureteric orifice
  C67.7 Malignant neoplasm of urachus
  C67.8 Malignant neoplasm of overlapping sites of bladder
  C67.9 Malignant neoplasm of bladder, unspecified

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, lue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2016 Forward     

06/01/2019 

Annual review adding coverage for: Tecentriq™ is considered MEDICALLY NECESSARY in combination with paclitaxel protein-bound for the treatment of adult patients with unresectable locally advanced or metastatic TNBC whose tumors express PD-L1 (PD-L1 stained tumor-infiltrating immune cells (IC) of any intensity covering > 1% of the tumor area), as determined by an FDA-approved test, and Tecentriq™ is considered MEDICALLY NECESSARY in combination with carboplatin and etoposide, for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC). No other changes made. 

06/13/2018 

Annual review, adding coverage for FDA-approved use in NSCLC. No other changes to policy. 

11/27/2017 

Updating with 2018 coding. No other changes. 

06/07/2017 

Annual review, no change to policy intent. 

09/01/2016 

Updating to add investigational statement. 

08/08/20216 

Added HCPCS code C9483 to coding section. 

06/15/2016

NEW POLICY

 


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