Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	I-127-007
Topic:	Blinatumomab (Blincyto)
Section:	Injections
Effective Date:	August 20, 2018
Issue Date:	August 20, 2018
Last Reviewed:	July 2018

Blinatumomab (Blincyto™) is a bispecific CD19-directed CD3 T-cell engager (BiTE) antibody construct product. Blinatumomab (Blincyto) engages the T lymphocytes to destroy leukemia cells. The drug acts as a connector between CD19 protein, which is found on the surface of most B-cell lymphoblasts, and CD3 protein, which is found on T-cell lymphocytes. BiTE antibody constructs are modified antibodies that are designed to engage two different targets simultaneously, thereby juxtaposing T cells to cancer cells.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Blinatumomab (Blincyto) may be considered medically necessary as a single-agent therapy for ANY of the following indications:

Treatment of relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) in adults and children; or
Treatment of B-cell precursor ALL in adults and children in first or second complete remission with minimal residual disease (MRD) greater than or equal to 0.1%; or
Consolidation therapy for Philadelphia chromosome-negative B-ALL in adolescent and young adult individuals, and in adults less than 65 years of age with minimal residual disease positive (MRD+) following a complete response to induction therapy; or
Relapsed/refractory Philadelphia chromosome-positive B-ALL in individuals with ANY ONE of the following:

Tyrosine Kinase Inhibitor (TKI) intolerance; or
TKI refractory.

The use of blinatumomab (Blincyto) is considered experimental/investigational and, therefore, non-covered for all other indications. Scientific literature does not support the use of blinatumomab (Blincyto) for other indications.

Procedure Codes

J9039

NOTE: Dosage recommendations per the FDA label.

Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Hospitalization is recommended for the first nine (9) days of the first cycle and the first two (2) days of the second cycle of blinatumomab (Blincyto).

For all subsequent cycle starts and re-initiation (eg, if treatment is interrupted for 4 or more hours), supervision by a healthcare professional or hospitalization is recommended.

The administration of blinatumomab (Blincyto) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Links

Link to Provider Resource Center for the Medical Policy Update

08/2018, Criteria Revised for Blinatumomab (Blincyto)

Link to Diagnosis Codes

Link to References

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.