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HealthPartners

Coverage criteria policies

Bevacizimab (Avastin®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

No authorization is needed when prescribed by an oncologist for use in FDA-approved indications or when used by an ophthalmologist for macular degeneration or other ophthalmic indication.

Off-label use for indications other than macular degeneration and other ophthalmic conditions, and use by providers who are not oncologists or ophthalmologists, requires prior approval through HealthPartners Pharmacy Administration.

Coverage

Coverage for bevacizumab is subject to the indications listed below, and per your plan documents.

Coverage for Medicare products will be provided according to the Article related to the Local Coverage Determination for Avastin®. There is a link to the Article in the Related Content section to the right.

Avastin® is generally covered when:

  1. Prescribed by an ophthalmologist for treatment of age-related macular degeneration, OR
  2. Prescribed by an oncologist for FDA-approved oncology indications.

Definitions

Avastin is a vascular endothelial growth factor-specific angiogenesis inhibitor indicated for the treatment of:

  • Metastatic colorectal cancer, with intravenous 5-fluorocil-based chemotherapy for first- or second-line treatment.
  • Metastatic colorectal cancer, with fluoropyrimidine-, irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line Avastin-containing regimen.
  • Non-squamous non-small cell lung cancer, with carboplatin and paclitaxel for first line treatment of unresectable, locally advanced recurrent or metastatic disease.
  • Glioblastoma, as a single agent for adult patients with progressive disease following prior therapy.
    • Effectiveness based on improvement in objective response rate. No data available demonstrating improvement in disease-related symptoms or survival with Avastin.
  • Metastatic renal cell carcinoma with interferon alfa.
  • Cervical cancer, in combination with paclitaxel and cisplatin or paclitaxel and topotecan in persistent, recurrent, or metastatic disease.
  • Platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer that is
    • platinum-resistant in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan,
    • platinum-sensitive in combination with carboplatin and paclitaxel or in combination with carboplatin and gemcitabine, followed by Avastin as a single agent

Avastin is not indicated for adjuvant treatment of colon cancer.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Code

Codes

Description

J9035

Injection, bevacizumab, 10 mg

C9257

Injection, bevacizumab, 0.25 mg

NDC Codes

Codes

Description

50242006001

100mg /4mL single dose vials

50242006101

400mg/16mL single dose vials

ICD-10 Codes
The following codes will be paid without authorization:

Codes

Description

C18.0-C18.9

Malignant neoplasm of cecum, appendix, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, overlapping sites of colon, colon (unspecified)

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.0-C21.8

Malignant neoplasm of anus, unspecified, anal canal, cloacogenic zone, overlapping sites of rectum, anus and anal canal

C33

Malignant neoplasm of trachea

C34.00-C34.92

Malignant neoplasm of bronchus and/or lung

C45.1

Mesothelioma of peritoneum

C48.1

Malignant neoplasm of specified parts of peritoneum

C48.8

Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum

C53.0-C53.9

Malignant neoplasm of endocervix, exocervix, overlapping sites of cervix uteri, and cervix uteri (unspecified)

C56.1-C56.9

Malignant neoplasm of right or left ovary, or unspecified ovary

C57.00-C57.4

Malignant neoplasm of fallopian tube, broad ligament, round ligament, (unspecified, right, or left), parametrium, or uterine adnexa (unspecified),

C64.1-C64.9

Malignant neoplasm of kidney (right, left, or unspecified), except renal pelvis

C65.1-C65.9

Malignant neoplasm of renal pelvis (right, left, or unspecified)

C66.1-C66.9

Malignant neoplasm of ureter (right, left, or unspecified)

C68.0-C68.9

Malignant neoplasm of urethra, paraurethral glands, overlapping sites of urinary organs, or urinary organ unspecified

C71.0-C71.9

Malignant neoplasm of cerebrum (except lobes and ventricles), frontal, temporal, parietal, or occipital lobes, cerebral ventricle, cerebellum, brain stem, overlapping sites of brain, or brain unspecified

E08.311-E08.359

Diabetes mellitus due to underlying condition with unspecified, mild, moderate or severe diabetic retinopathy; and with or without macular edema

E08.3591

DIAB WITH PROLIF DIABETIC RTNOP WITHOUT MACULAR EDEMA, R EYE

E08.3592

DIAB WITH PROLIF DIAB RTNOP WITHOUT MACULAR EDEMA, LEFT EYE

E08.3593

DIAB WITH PROLIF DIABETIC RTNOP WITHOUT MACULAR EDEMA, BI

E08.3599

DIAB WITH PROLIF DIABETIC RTNOP WITHOUT MACULAR EDEMA, UNSP

E09.311-E09.359

Drug or chemical induced diabetes mellitus with unspecified, mild, moderate or severe diabetic retinopathy; and with or without macular edema

E09.3591

DRUG/CHEM DIAB WITH PROLIF DIAB RTNOP W/O MCLR EDEMA, R EYE

E09.3592

DRUG/CHEM DIAB WITH PROLIF DIAB RTNOP W/O MCLR EDEMA, L EYE

E09.3593

DRUG/CHEM DIAB WITH PROLIF DIAB RTNOP WITHOUT MCLR EDEMA, BI

E09.3599

DRUG/CHEM DIAB WITH PROLIF DIAB RTNOP W/O MCLR EDEMA, UNSP

E10.10-E10.9

Type 1 diabetes mellitus with or without other disease or complications

E11.00-E11.9

Type 2 diabetes mellitus with or without other disease or complications

E13.00-E13.9

Other specified diabetes mellitus with or without other disease or complications

G45.3

Amaurosis fugax

H31.101-H31.109

Choroidal degeneration unspecified; right, left, bilateral or unspecified eye

H31.111-H31.119

Age-related choroidal atrophy; right, left, bilateral or unspecified eye

H31.121-H31.129

Diffuse secondary atrophy of choroid; right, left, bilateral or unspecified eye

H34.00-H34.219

Retinal artery occlusion; transient, central, or partial; unspecified, right, left, or bilateral eye(s)

H34.231-H34.239

Retinal artery branch occlusion; right, left, bilateral, or unspecified eye(s)

H34.811-H34.819

Central retinal vein occlusion; right, left, bilateral, or unspecified eye(s)

H34.821-H34.829

Venous engorgement; right, left, bilateral, or unspecified eye(s)

H34.831-H34.839

Tributary (branch) retinal vein occlusion; right, left, bilateral, or unspecified eye(s)

H34.9

Unspecified retinal vascular occlusion

H35.00

Unspecified background retinopathy

H35.011-H35.019

Changes in retinal vascular appearance; right, left, bilateral, or unspecified eye(s)

H35.021-H35.029

Exudative retinopathy; right, left, bilateral, or unspecified eye(s)

H35.031-H35.039

Hypertensive retinopathy; right, left, bilateral, or unspecified eye(s)

H35.32

EXUDATIVE AGE-RELATED MACULAR DEGENERATION

H35.321

EXUDATIVE AGE-RELATED MACULAR DEGENERATION, RIGHT EYE

H35.3210

EXUDATIVE AGE-REL MCLR DEGN, RIGHT EYE, STAGE UNSPECIFIED

H35.3211

EXDTVE AGE-REL MCLR DEGN, RIGHT EYE, WITH ACTV CHRDL NEOVAS

H35.3212

EXDTVE AGE-REL MCLR DEGN, RIGHT EYE, WITH INACT CHRDL NEOVAS

H35.3213

EXUDATIVE AGE-REL MCLR DEGN, RIGHT EYE, WITH INACTIVE SCAR

H35.322

EXUDATIVE AGE-RELATED MACULAR DEGENERATION, LEFT EYE

H35.3220

EXUDATIVE AGE-RELATED MCLR DEGN, LEFT EYE, STAGE UNSPECIFIED

H35.3221

EXDTVE AGE-REL MCLR DEGN, LEFT EYE, WITH ACTV CHRDL NEOVAS

H35.3222

EXDTVE AGE-REL MCLR DEGN, LEFT EYE, WITH INACT CHRDL NEOVAS

H35.3223

EXUDATIVE AGE-REL MCLR DEGN, LEFT EYE, WITH INACTIVE SCAR

H35.323

EXUDATIVE AGE-RELATED MACULAR DEGENERATION, BILATERAL

H35.3230

EXUDATIVE AGE-REL MCLR DEGN, BILATERAL, STAGE UNSPECIFIED

H35.3231

EXUDATIVE AGE-REL MCLR DEGN, BI, WITH ACTV CHRDL NEOVAS

H35.3232

EXUDATIVE AGE-REL MCLR DEGN, BI, WITH INACT CHRDL NEOVAS

H35.3233

EXUDATIVE AGE-REL MCLR DEGN, BILATERAL, WITH INACTIVE SCAR

H35.329

EXUDATIVE AGE-RELATED MACULAR DEGENERATION, UNSPECIFIED EYE

H35.3290

EXUDATIVE AGE-RELATED MCLR DEGN, UNSP, STAGE UNSPECIFIED

H35.3291

EXUDATIVE AGE-REL MCLR DEGN, UNSP, WITH ACTV CHRDL NEOVAS

H35.3292

EXUDATIVE AGE-REL MCLR DEGN, UNSP, WITH INACT CHRDL NEOVAS

H35.3293

EXUDATIVE AGE-RELATED MCLR DEGN, UNSP, WITH INACTIVE SCAR

H35.041-H35.049

Retinal micro-aneurysms, unspecified; right, left, bilateral, or unspecified eye(s)

H35.051-H35.059

Retinal neovascularization, unspecified; right, left, bilateral, or unspecified eye(s)

H35.061-H35-069

Retinal vasculitis; right, left, bilateral, or unspecified eye(s)

H35.071-H35.079

Retinal telangiectasis; right, left, bilateral, or unspecified eye(s)

H35.09

Other intraretinal microvascular abnormalities

H35.101-H35.169

Retinopathy of prematurity; eye; unspecified; stages 0-5; right, left, bilateral, or unspecified eye(s)

H35.171-H35.179

Retrolental fibroplasia; right, left, bilateral, or unspecified eye(s)

H35.20-H35.23

Other non-diabetic proliferative retinopathy; unspecified, right, left, or bilateral eye(s)

H35.30

Unspecified macular degeneration

H35.31

Nonexudative age-related macular degeneration

H35.32

Exudative age-related macular degeneration

H35.341-H35.349

Macular cyst, hole, or pseudohole; right, left, bilateral, or unspecified eye(s)

H35.351-H35.359

Cystoid macular degeneration; right, left, bilateral, or unspecified eye(s)

H35.361-H35.369

Drusen (degenerative) of macula; right, left, bilateral, or unspecified eye(s)

H35.431-H35.439

Paving stone degeneration of retina; right, left, bilateral, or unspecified eye(s)

H35.441-H35.449

Age-related reticular degeneration of retina; right, left, bilateral, or unspecified eye(s)

H35.451-H35.459

Secondary pigmentary degeneration; right, left, bilateral, or unspecified eye(s)

H35.461-H35.469

Secondary vitreoretinal degeneration; right, left, bilateral, or unspecified eye(s)

H35.50

Unspecified hereditary retinal dystrophy

H35.51

Vitreoretinal dystrophy

H35.52

Pigmentary retinal dystrophy

H35.53

Other dystrophies primarily involving the sensory retina

H35.54

Dystrophies primarily involving the retinal pigment epithelium

H35.60-H35.63

Retinal hemorrhage; unspecified, right, left or bilateral eye(s)

H35.70

Unspecified separation of retinal layers

H35.711-H35.719

Central serous chorioretinopathy; right, left, bilateral, or unspecified eye(s)

H35.721-H35.729

Serous detachment of retinal pigment epithelium; right, left, bilateral, or unspecified eye(s)

H35.731-H35.739

Hemorrhagic detachment of retinal pigment epithelium; right, left, bilateral, or unspecified eye(s)

H35.81

Retinal edema

H5.82

Retinal ischemia

H35.89

Other specified retinal disorders

H35.9

Unspecified retinal disorder

H36

Retinal disorders in diseases classified elsewhere

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Avastin Prescribing Information. Genentech, Inc. December 2016.

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Policy activity

  • 01/03/2005 - Date of origin
  • 06/09/2017 - Effective date
Review date
  • 02/2017

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