Akynzeo (fosnetupitant and palonosetron) for injection — Coverage Criteria
Criteria for medical-benefit coverage and prior authorization of Akynzeo injection for prevention of chemotherapy-induced acute and delayed nausea and vomiting in adults receiving highly or moderately emetogenic chemotherapy; applies to Anthem members under the medical benefit.
Coding Reviewed: Removed ICD-10-CM C00.0-C96.9, D00.00-D09.9, Z85.00-Z85.9. Added ICD-10-CM T45.1X5A-T45.1X5S, T45.95XA-T45.95XS, T50.905A-T50.905S, Z51.12.
Annual Review: No change. Coding Reviewed: No changes.
Coverage Criteria for Akynzeo (fosnetupitant and palonosetron) Injection
Initial and repeat course coverage
Covered when ALL of the following are met
Excludes use with anthracycline plus cyclophosphamide as not studied
Akynzeo for injection is not approved for prevention of nausea and vomiting associated with anthracycline plus cyclophosphamide chemotherapy. Requests for Akynzeo may also be denied when the documented clinical criteria are not met or when used for indications other than the specified prevention of acute and delayed chemotherapy-induced nausea and vomiting in adults receiving highly or moderately emetogenic chemotherapy in combination with dexamethasone.
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