CurrentcareoregonPolicy N/A

Myeloid Growth Factors (G-CSFs) — Prior Authorization Guideline

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Prior authorization guideline for myeloid growth factors (e.g., Fylnetra, Nivestym) governing medical necessity criteria and approval length for CareOregon members.

Policy Summary

Payercareoregon

PolicyMyeloid Growth Factors (G-CSFs) — Prior Authorization Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for myeloid growth factors; requests meeting criteria may be approved for up to 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval length

Fylnetra, Nivestymexample products

febrile neutropeniaprimary covered indications

high-risk conditionsadditional covered

Coverage criteria for myeloid growth factors

Policy Summary

Payercareoregon

PolicyMyeloid Growth Factors (G-CSFs) — Prior Authorization Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for myeloid growth factors; requests meeting criteria may be approved for up to 12 months.

SourceLink

On This Page

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CurrentcareoregonPolicy N/A

Myeloid Growth Factors (G-CSFs) — Prior Authorization Guideline

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Sign up for all careoregon policy alerts

Know when careoregon releases new policies or updates existing guidance.

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Prior authorization guideline for myeloid growth factors (e.g., Fylnetra, Nivestym) governing medical necessity criteria and approval length for CareOregon members.

Policy Summary

Payercareoregon

PolicyMyeloid Growth Factors (G-CSFs) — Prior Authorization Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for myeloid growth factors; requests meeting criteria may be approved for up to 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval length

Fylnetra, Nivestymexample products

febrile neutropeniaprimary covered indications

high-risk conditionsadditional covered

Coverage criteria for myeloid growth factors

Policy Summary

Payercareoregon

PolicyMyeloid Growth Factors (G-CSFs) — Prior Authorization Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for myeloid growth factors; requests meeting criteria may be approved for up to 12 months.

SourceLink

On This Page

Initial and specified coverage criteria

Covered when any ONE of the following is met:

Prevention of febrile neutropenia: Request is for prevention of febrile neutropenia in patients undergoing myelosuppressive chemotherapy.

Treatment of febrile neutropenia with risk factors

At least one risk factor: Patient has at least one of the following risk factors: expected hospital stay > 10 days; profound neutropenia (< 100 cells/uL); age > 65; pneumonia or other clinically documented infection; sepsis syndrome; invasive fungal infections; prior episode of febrile neutropenia; developed fever after being hospitalized (hospital-acquired infection).

Neutropenia related to Hepatitis C treatment: Diagnosis of neutropenia associated with Hepatitis C treatment (pending medical necessity review).

Specified diagnoses or procedures: One of the following diagnoses/procedures: bone marrow transplant (allogenic or autologous); autologous peripheral blood progenitor cells (PBPC) transplant; severe chronic neutropenia; AIDS; myelodysplastic syndromes.

Requests for myeloid growth factors (G-CSFs) to treat neutropenia without fever after chemotherapy are not an approved indication under this guideline and should be denied for appropriateness.

Neutropenia occurring after chemotherapy without accompanying fever does not meet the criteria for G-CSF therapy; such requests should be denied because treatment of afebrile neutropenia following chemotherapy is explicitly not an indication for G-CSF use.

Indications and regimens covered

Covered Regimen	Coverage Status
Use of myeloid growth factors (e.g., Fylnetra, Nivestym) for prevention of febrile neutropenia in patients receiving myelosuppressive chemotherapy	Covered

Covered Regimen	Coverage Status
G-CSF for treatment of febrile neutropenia when patient meets criteria for treatment AND has at least one listed risk factor (expected hospital stay >10 days; profound neutropenia <100 cells/µL; age >65; pneumonia or other documented infection; sepsis syndrome; invasive fungal infections; prior episode of febrile neutropenia; developed fever after being hospitalized).	Covered

Prior authorization and provider requirements

Prior Authorization

Prior authorization required for myeloid growth factors

Prior authorization is required for myeloid growth factors. Requests that meet the policy criteria — such as prevention of febrile neutropenia in patients receiving myelosuppressive chemotherapy, treatment of febrile neutropenia with qualifying risk factors, or specified high-risk diagnoses/procedures — may be approved under prior authorization.

Documentation Required

Document fever and qualifying risk factors for neutropenia treatment

Providers must follow the policy criteria when requesting G-CSF; the policy explicitly states that treatment of neutropenia without fever after chemotherapy is not an approved indication and should be denied, so ensure documentation addresses fever status and applicable risk factors.

Confirm and document presence of fever when requesting G-CSF for neutropenia after chemotherapy.
If treating febrile neutropenia, document at least one qualifying risk factor when applicable (see policy).

Prior Authorization

Prior authorization and approval length (12 months)

Prior authorization is required and, when approved, authorization length is 12 months. Example product names listed in the policy include Fylnetra and Nivestym.

Approval length: 12 month(s).
Example product names: Fylnetra, Nivestym.

Denial Risk

Denial risk: afebrile neutropenia after chemotherapy

Requests for G-CSF to treat neutropenia after chemotherapy when there is no fever (afebrile neutropenia) should be denied as not an indication for use under this policy.

Key definitions

inv-09: Febrile neutropenia — definition and note that neutropenia without fever post-chemotherapy is not approved.

DefinitionFebrile neutropenia: neutropenia accompanied by fever (treatment indicated when fever is present).

Not covered — afebrile neutropenia after chemotherapyTreatment of neutropenia without fever after chemotherapy is NOT an indication for G-CSF use and should be denied for appropriateness.

Related coverage criteriaCovered when request is for prevention of febrile neutropenia in patients undergoing myelosuppressive chemotherapy OR for treatment of febrile neutropenia when qualifying risk factors are present.

inv-10: Acute radiation poisoning — listed as a background condition associated with use of myeloid growth factors.

Listed background conditionAcute radiation poisoning is included in the policy background as a condition associated with use of myeloid growth factors.

ContextMyeloid growth factors are used for prevention or treatment of febrile neutropenia and may be considered for certain high-risk conditions; acute radiation poisoning is identified among those background conditions.

Implication for requestsPresence of acute radiation poisoning may be relevant to consideration of G-CSF use per the policy background.

Background and clinical context

Myeloid growth factors (G-CSFs) are intended to prevent or treat febrile neutropenia associated with myelosuppressive chemotherapy or to manage neutropenia in specified high-risk situations. The policy specifies use for prevention of febrile neutropenia in patients receiving myelosuppressive chemotherapy and for treatment of febrile neutropenia when qualifying risk factors are present; they are not indicated for routine treatment of neutropenia without fever after chemotherapy.