Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesHematology/OncologyBaylor Scott & White chemo coverage Prior Auth | O…
    Ask Trek AI about this page
    CurrentBaylor Scott & White Health PlanPolicy 219

    Cancer Chemotherapy / Therapy Guidelines

    Customize your policy alerts

    Sign up for Baylor Scott & White Health Plan Policy 219 alerts

    Get alerted when Policy 219 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines medical necessity criteria, documentation, and limits for oncology medications and chemotherapy regimens for Baylor Scott & White Health Plan members; applies to all lines of business unless otherwise indicated.

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyCancer Chemotherapy / Therapy Guidelines
    Policy CodePolicy 219
    Change TypeNo material clinical or coverage changes
    Effective DateMar 1, 2026
    Last ReviewFeb 26, 2026
    Next Review DateFeb 26, 2027
    Key ActionObtain prior authorization for oncology medications (HCPCS A9600-A9699 and J9000-J9999) and ensure requests meet the policy's medical necessity criteria.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsMaximum authorization duration
    A9600-A9699, J9000-J9999

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    HCPCS ranges
    NCCN Cat 1/2APreferred compendia
    2 yearsPD-1/PD-L1 max initial

    Coverage Criteria

    General oncology medication medical necessity criteria

    Covered when ALL of the following are met:

    Primary requirements: 1) Requested drug is being used for a medically accepted indication as defined by FDA labeling OR NCCN Drugs & Biologics Compendium Category 1 or 2A OR specified compendia recommendations (Clinical Pharmacology 'Strong For', AHFS-DI supportive narrative, Wolters Kluwer Lexi-Drugs 'Use: Off-Label' with Evidence Level A) OR peer-reviewed medical literature from listed journals; 2) Dose and frequency are consistent with FDA labeling, NCCN, listed compendia, or indication‑specific peer‑reviewed literature; 3) For non-preferred oncology medications, the member has had failure of an adequate trial of, or clinically significant intolerance/contraindication to, preferred medications in the same class (see BSWHP policies 306 and 307); 4) For renewal requests, documentation must indicate no evidence of disease progression; 5) Approval duration is the shortest clinically appropriate, up to 12 months;

    See Appendix A for drug/class specific limits (e.g., PD-1/PD-L1 inhibitors maximum initial therapy length of 2 years for metastatic NSCLC).

    Oncology medications and therapies that received accelerated approval but whose indication has subsequently been withdrawn by the U.S. Food and Drug Administration (FDA) are not considered medically necessary for the withdrawn indication. Coverage will be denied for such uses because clinical benefit has not been established despite any other compendia or literature citations.

    Recommendations listed as NCCN Category 3 are considered unproven and not medically necessary and will not meet the policy's criteria for coverage.

    Coding and Duration Limits

    Prior Authorization

    Prior Authorization Required

    Prior authorization may be required for oncology medications billed under HCPCS ranges A9600-A9699 and J9000-J9999. Providers must submit a prior authorization request and supporting documentation that demonstrates the member meets the policy's clinical criteria (see policy body).

    • Affected HCPCS ranges: A9600 - A9699, J9000 - J9999
    Denial Risk

    Prior Failure Without Supporting Evidence

    Prior authorization requests lacking documentation of prior therapeutic failure (when the policy requires demonstrated prior failure) or lacking adequate supporting evidence of indication, dosing, and duration are at risk for denial. If the policy requires prior failure of a specified therapy, the provider must document prior trial(s), duration, response, and reason for discontinuation (e.g., intolerance, progression).

    • Document prior therapies: drug name, dates of therapy, reason for discontinuation, and objective evidence of failure or intolerance.

    Provider Actions and Documentation Requirements

    Step Therapy

    Step therapy: fail preferred agents in same class before non-preferred coverage

    For non-preferred oncology medications, the member must have had an adequate trial and failed, or have a clinically significant intolerance or contraindication to, preferred medications in the same pharmacologic class before coverage of the non-preferred agent.

    • Follow BSWHP step therapy policies 306 (Commercial) and 307 (Medicare) for specifics on required trials and exceptions.
    Documentation Required

    Renewals require no disease progression and off‑label literature submission

    Renewal requests must document that there is no evidence of disease progression; any request supporting off‑label use must include the relevant peer‑reviewed medical literature published in full text in an accepted journal.

    • Accepted journals are listed in the policy (e.g., Journal of Clinical Oncology, NEJM, Lancet, Journal of the American Medical Association, etc.).
    • Abstracts and case reports are excluded — supply full‑text manuscripts when supporting off‑label indications.

    Background and Evidence Sources

    This policy bases medical necessity determinations on FDA labeling, NCCN Drugs & Biologics Compendium Category 1 or 2A, and selected compendia (for example, DrugDex/Thomson Micromedex, Clinical Pharmacology, AHFS-DI, and Wolters Kluwer Lexi-Drugs) or peer-reviewed literature. It notes the role and limits of accelerated approvals and clarifies that withdrawn accelerated-approval indications are not considered medically necessary.

    Definitions

    Medically accepted indication — acceptance criteria
    FDA labelingUse supported by United States Food and Drug Administration (FDA) labeling consistent with product labeling
    NCCN guidanceNCCN Drugs & Biologics Compendium with Category 1 or 2A as proven and medically necessary (Category 2B requires detailed review; Category 3 is unproven and not medically necessary)
    Selected compendiaSpecific compendia recommendations such as Clinical Pharmacology ('Strong For'), AHFS-DI with supportive narrative, or Lexi-Drugs rated Evidence Level A
    Peer-reviewed literaturePeer-reviewed medical literature in listed journals may support medically accepted indications when compendia or FDA labeling do not

    Line of Therapy Criteria

    Line of therapy

    Line of therapy guidance: Policy applies across lines of care; specific determination of first-line versus subsequent lines should follow FDA labeling, NCCN or regimen-specific guidance and applicable step therapy requirements.

    Refer to Appendix A for regimen-specific limits (e.g., PD-1/PD-L1 class limits) and to Step Therapy policies 306/307 where non-preferred agents are involved.

    Biomarker Requirements

    PD-L1 — biomarker requirement details
    Biomarker referencedPD-L1 is included as a biomarker referenced in policy references (examples include trials such as KEYNOTE); policy relies on FDA/NCCN guidance for biomarker-driven indications
    RequirementPolicy notes PD-L1 as an example biomarker for indications but does not specify a single numeric threshold; follow FDA or NCCN guidance for indication-specific PD-L1 thresholds
    DocumentationWhen biomarker-driven indication is requested, documentation should align with FDA labeling, NCCN guidance, or supporting peer-reviewed literature cited in the request

    Covered Regimens and Appendix

    Regimen / Drug classApplicable drugs (Appendix A)Maximum initial therapy lengthCoverage status
    PD-1/PD-L1 inhibitorsBavencio (Avelumab); Imfinzi (Durvalumab); Jemperli (Dostarlimab); Keytruda (Pembrolizumab); Libtayo (Cemiplimab); Loqtorzi (Toripalimab); Opdivo (Nivolumab); Opdualag (Nivolumab and Relatimab-rmbw); Tecentriq (Atezolizumab); Tecentriq Hybreza (Atezolizumab and Hyaluronidase-tqjs); Tevimbra (Tislelizumab); Zynyz (Retifanlimab-dlwr)Maximum total length of initial therapy for metastatic non-small cell lung cancer: 2 yearsCovered with criteria

    Related Policies

    See related policies for step therapy and coverage of medications administered under the medical benefit: Policy 306 and Policy 307 (step therapy read-with references), and Policy 215 (medications covered under the medical insurance policy).

    Revision History

    2026-03-01Policy effective dateLatest

    Policy effective date set to 03/01/2026.

    2026-02-26Last review

    Policy last reviewed on 02/26/2026.

    2027-02-26Next scheduled review

    Next routine review scheduled for 02/26/2027.

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyCancer Chemotherapy / Therapy Guidelines
    Policy CodePolicy 219
    Change TypeNo material clinical or coverage changes
    Effective DateMar 1, 2026
    Last ReviewFeb 26, 2026
    Next Review DateFeb 26, 2027
    Key ActionObtain prior authorization for oncology medications (HCPCS A9600-A9699 and J9000-J9999) and ensure requests meet the policy's medical necessity criteria.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Duration LimitsProvider Actions and Documentation RequirementsBackground and Evidence SourcesDefinitionsLine of Therapy CriteriaBiomarker RequirementsCovered Regimens and AppendixRelated PoliciesRevision History
  1. If prior failure is required but not documented, the request may be denied.
    2. Oncology HCPCS RangesHCPCS
    A9600 - A9699Oncology and supportive care drugs
    J9000 - J9999Antineoplastic and other injectable drugs
    Denial Risk

    Withdrawn accelerated‑approval indications are not medically necessary

    Oncology medications or therapies that received accelerated approval but were subsequently withdrawn by the FDA for that indication are not considered medically necessary and will be denied.

    • This applies regardless of NCCN, compendia, or peer‑reviewed literature status for that indication.
    Denial Risk

    Prior failure without high‑quality supporting evidence may lead to denial

    Requests for drugs previously tried and discontinued for lack of efficacy may be subject to an off‑label review and can be denied if not supported by NCCN or high‑quality literature (prospective phase 2 or 3 full‑manuscript studies in CMS‑supported journals).

    • Provide robust supporting evidence (NCCN Category 1/2A or prospective phase 2/3 full manuscripts) when requesting re‑coverage after prior failure.