CurrentAnthemPolicy CC-0155

Ethyol (amifostine) injection — Medical Drug Clinical Criteria

Defines medical necessity criteria, coding, and clinical guidance for Ethyol (amifostine) when requested under the medical benefit; applies to providers and Anthem authorization reviewers.

Policy Summary

PayerAnthem

PolicyEthyol (amifostine) injection — Medical Drug Clinical Criteria

Policy CodePolicy CC-0155

Change TypeAnnual review — no material clinical changescoding updates recorded

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the member meets an approval pathway (under 19 years old OR FDA‑approved indication for advanced ovarian cancer with cisplatin prophylaxis OR post‑operative head and neck radiation xerostomia prophylaxis).

SourceLink

POLICY UPDATE CHANGES

Annual Review: No Changes. Administrative update for age. Coding Reviewed: Removed ICD-10-CM Z85.40, Z85.41, Z85.42, Z85.44.

Added HCPCS code J0207 and ICD-10-CM codes C56.1-C56.9, C76.0; removed some prior codes in earlier years.

2FDA-approved indications listed

J0207HCPCS

C56.1-C56.9, C76.0ICD-10 codes

Under 19Age-based condition

Coverage Criteria for Ethyol (amifostine)

Covered Indications / Approval Criteria

Requests for Ethyol (amifostine) may be approved if the following criteria are met:

Approval pathways: One of the following pathways must be met:

Pathway A: Pediatric: Individual is under 19 years of age.

Pathway B: Advanced ovarian cancer with cisplatin nephrotoxicity prophylaxis: Individual has a diagnosis of advanced ovarian cancer AND is using Ethyol for prophylaxis of cisplatin-associated cumulative renal toxicity (prophylaxis in cisplatin nephropathy).

Pathway C: Head and neck post-operative radiation xerostomia prophylaxis: Individual has a diagnosis of head and neck cancer AND is using Ethyol for prophylaxis of post-operative radiation-induced xerostomia when the parotid glands are substantially within the radiation field.

Policy Summary

PayerAnthem

PolicyEthyol (amifostine) injection — Medical Drug Clinical Criteria

Policy CodePolicy CC-0155

Change TypeAnnual review — no material clinical changescoding updates recorded

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Ethyol (amifostine) is FDA-approved for two specific cytoprotective uses and should be used with caution outside those settings. Specifically, it is approved to reduce cumulative renal toxicity from repeated cisplatin administration in patients with advanced ovarian cancer and to reduce the incidence of moderate to severe xerostomia in patients receiving post‑operative radiation for head and neck cancer when the radiation port includes a substantial portion of the parotid glands. Ethyol should not be used in other settings where chemotherapy can produce a significant survival benefit or cure, or in patients receiving definitive radiotherapy. When considering Ethyol, verify that the requested use matches one of the approved indications or an authorized pathway (for example, pediatric approval pathway) before approving therapy.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization may be required. Requests for Ethyol (amifostine) will be considered for approval only when the specified clinical criteria are met: either the individual is under 19 years of age OR the individual has advanced ovarian cancer and is using Ethyol as prophylaxis for cisplatin nephropathy, or the individual has head and neck cancer and is using Ethyol for prophylaxis of post-operative radiation-induced xerostomia.

Affected drug: Injection, amifostine (Ethyol) 500 mg
Approval pathways: Age-based (individual < 19 years) OR Indication-based (advanced ovarian cancer for cisplatin nephropathy prophylaxis; head and neck cancer for prophylaxis of post-operative radiation-induced xerostomia).

Documentation Required

Provider Action

Provider must submit a prior authorization request with clinical documentation supporting the diagnosis and intended prophylactic use (e.g., medical records showing diagnosis of advanced ovarian cancer or head and neck cancer, chemotherapy regimen including cisplatin when applicable, or planned/ongoing post-operative radiation). Verify member benefits and medical benefit coverage prior to authorization submission.

Include: relevant diagnosis, age, indication for prophylactic use, chemotherapy/radiation treatment plan, and prior treatments.
Verify member's contract benefits and submit any required supporting clinical notes or imaging.

Note

Coding and Documentation

The following codes are provided for informational purposes only. Inclusion or exclusion of codes does not determine coverage or reimbursement; verify member benefits and billing guidance prior to claim submission.

Procedure/treatment and diagnosis codes related to administration of Ethyol and the underlying cancer diagnoses should be documented and submitted as applicable.

Denial Risk

Requests for Ethyol (amifostine) will be denied when the criteria above are not met or for any other indications not listed as approved.

Denial will be issued if neither age-based nor indication-based criteria are satisfied.
Clinical documentation that does not substantiate prophylactic use for the specified indications or age < 19 will result in non-approval.

Definitions / Uses

Use of Ethyol to reduce cumulative renal toxicity associated with repeated cisplatin administration

DefinitionEthyol (amifostine) prophylaxis to reduce cumulative renal toxicity from repeated cisplatin administration in patients with advanced ovarian cancer.

MechanismIntravenous prodrug converted to a free thiol that accumulates in normal tissues to detoxify reactive cisplatin metabolites.

FDA‑approved populationPatients with advanced ovarian cancer receiving repeated cisplatin administration for whom reduction of cumulative renal toxicity is intended.

Not recommendedShould not be used in other settings where chemotherapy can produce a significant survival benefit or cure, or in patients receiving definitive radiotherapy.

Route of administrationIntravenous.

Use of Ethyol to reduce incidence of moderate to severe xerostomia in post-operative head and neck radiation where parotid glands are substantially in the radiation port

DefinitionEthyol (amifostine) prophylaxis to reduce the incidence of moderate to severe xerostomia after post‑operative radiation for head and neck cancer when the radiation port includes a substantial portion of the parotid glands.

MechanismIntravenous prodrug dephosphorylated to a free thiol that scavenges radiation‑generated reactive oxygen species in normal tissues.

FDA‑approved indicationPatients undergoing post‑operative radiation for head and neck cancer with parotid glands substantially in the radiation field to reduce moderate to severe xerostomia.

Contraindication noteShould not be used in patients receiving definitive radiotherapy or in other settings where therapy offers significant chance of cure or survival benefit.

Route of administrationIntravenous.

C56.1-C56.9	Malignant neoplasm of ovary
C76.0	Malignant neoplasm of head, face and neck
Z85.43	Personal history of malignant neoplasm of ovary

OpenPayer

Ethyol (amifostine) injection — Medical Drug Clinical Criteria

Coverage Criteria for Ethyol (amifostine)

Initial Therapy Criteria

Coding

Provider Actions and Prior Authorization

Definitions / Uses

Background

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