Mylotarg (gemtuzumab ozogamicin) — Coverage Criteria
Clinical criteria governing prior authorization and medical necessity determinations for Mylotarg (gemtuzumab ozogamicin) for members with acute myeloid leukemia (AML) or acute promyelocytic leukemia (APL). Applies to provider requests for this drug under the member's medical benefit plan.
No material clinical or coverage changes in this revision.
Coverage Criteria for Mylotarg (gemtuzumab ozogamicin)
Approval Criteria
Requests for Mylotarg (gemtuzumab ozogamicin) may be approved if the following criteria are met:
Preserves OR logic between major approval paths.
Requests for Mylotarg (gemtuzumab ozogamicin) may not be approved if the above criteria are not met. Coverage is limited to the indications and clinical scenarios specifically listed in this policy; requests for uses outside those listed are not supported by this document.
Use of Mylotarg for any indication not specified in the approval criteria is considered not approved by this document and will not meet medical necessity requirements.
Coding (HCPCS and Diagnosis Codes)
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