TECENTRIQ™ (atezolizumab) - CAM 150

Policy
Tecentriq™ (atezolizumab) is considered MEDICALLY NECESSARY for members with metastatic non-small cell lung cancer who meet at least one of the following criteria: 

  • Adjuvant treatment (as a single agent) following resection and platinum-based chemotherapy in adults with stage II to IIIA non–small cell lung cancer (NSCLC) whose tumors have PD-L1 expression on ≥ 1% of tumor cells, as determined by an approved test

  • First-line treatment (single agent) of metastatic NSCLC in adults whose tumors have high PD-L1 expression (PD-L1 stained ≥ 50% of tumor cells [TC ≥ 50%] or PD-L1 stained tumor-infiltrating IC covering ≥ 10%), as determined by an approved test, with no epidermal growth factor receptor (EGFR) or ALK genomic tumor aberrations

  • First-line treatment (in combination with bevacizumab, paclitaxel, and carboplatin) of metastatic nonsquamous NSCLC in adults with no EGFR or ALK genomic tumor aberrations

  • First-line treatment (in combination with paclitaxel [protein bound] and carboplatin) of metastatic nonsquamous NSCLC in adults with no EGFR or ALK genomic tumor aberrations

  • Treatment (single agent) of metastatic NSCLC in adults with disease progression during or following platinum-containing chemotherapy (patients with EGFR or ALK genomic aberrations should have disease progression on approved therapy for EGFR or ALK genomic tumor mutations prior to receiving atezolizumab)

Tecentriq™ is considered MEDICALLY NECESSARY for treatment of Alveolar soft part sarcoma, unresectable or metastatic: Treatment of unresectable or metastatic alveolar soft part sarcoma in adult and pediatric patients ≥ 2 years of age.

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).

Tecentriq™ is considered MEDICALLY NECESSARY in treatment of unresectable or metastatic hepatocellular carcinoma (in combination with bevacizumab) in patients who have not received prior systemic therapy.

Tecentriq™ is considered MEDICALLY NECESSARY in treatment of BRAF V600 mutation-positive unresectable or metastatic melanoma (in combination with cobimetinib and vemurafenib). 

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 hours), 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, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated 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     

06/28/2023 Annual review, removed paragraph 1 medical necessity criteria for locally advanced or metastatic urothelial carcinoma, removed paragraph 3 medically necessity criteria for treatment of adult patients with unreselectable 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, adding coverage for: treatment of Alveolar soft part sarcoma, unreselectable or metastatic: Treatment of unreselectable or metastatic alveolar soft part sarcoma in adult and pediatric patients ≥ 2 years of age. 

06/22/2022

Annual review, updating criteria for use with metastatic non small cell lung cancer, adding criteria for unresectable or metastatic hepatoceullular carcinoma and BRAF V600 mutation positive unresectable or metastatic melanoma. No other changes.

06/23/2021 

Annual review, no change to policy intent. 

06/18/2020 

Annual review, no change to policy intent 

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. 

08/08/2016 

Added HCPCS code C9483 to coding section. 

06/15/2016

NEW POLICY

 

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