Oncology (Injectable) Lymphir Utilization Management Medical Policy
Defines prior authorization and medical necessity criteria, dosing, prescribing specialist requirement, and noncoverage conditions for Lymphir (denileukin diftitox-cxdl) for treatment of relapsed or refractory Stage I-III cutaneous T-cell lymphoma in adults.
New policy created for Lymphir (denileukin diftitox-cxdl) with review date 10/23/2024.
Coverage Summary
Defines prior authorization and medical necessity criteria for Lymphir (denileukin diftitox-cxdl) for the treatment of relapsed or refractory Stage I-III cutaneous T‑cell lymphoma in adults, including age ≥ 18 years, prior systemic therapy, serum albumin requirement, specialist prescribing requirement, and dosing limits. The policy references the FDA‑approved indication and NCCN guidance and includes a boxed warning for capillary leak syndrome and potentially life‑threatening reactions.
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