CurrentCignaPolicy 1705

Antiemetic Therapy

Defines medical necessity criteria, FDA indications and dosing, and quantity/duration limits for specified antiemetic products (Akynzeo, Anzemet, Emend, Sancuso, Varubi) under Cigna Coverage Policy 1705. Applies to adults and specified pediatric populations for prevention/treatment of chemotherapy-induced and postoperative nausea/vomiting when criteria are met.

Policy Summary

PayerCigna

PolicyAntiemetic Therapy

Policy CodePolicy 1705

Change TypeSelected revisions — removals of capsule and multiple injectable criteria

Effective DateMay 30, 2025

Next Review Date

Key ActionEnsure prior authorization workflows reflect the removal of specified Emend capsule and multiple injectable formulation criteria and document intolerance to generic aprepitant capsules when requesting Emend suspension.

POLICY UPDATE CHANGES

Removed Emend capsule medical necessity criteria from the policy.

Removed Akynzeo injection, Aloxi injection, Cinvanti injection, Emend injection, Sustol injection, Zofran solution, Zofran tablets, Zofran ODT and Zuplenz film medical necessity criteria from the policy.

Selected Revision 2 dates provided: 01/01/2025 and 05/30/2025 associated with the removals.

5Listed Products Covered

12Initial/Reauth Duration (months)

>=12Age threshold (years)

NCCN V1.2019Guideline cited

Coverage Summary

This policy (Coverage Policy Number 1705, effective 2025-05-30, status: CURRENT) defines medical necessity criteria for Antiemetic Therapy and is covered with criteria. Covered products addressed in the policy include: Akynzeo, Anzemet, Emend suspension, Sancuso transdermal, Varubi. The policy summarizes FDA indications, dosing, availability, and NCCN guideline context for antiemetic agents; however, customer benefit plan language controls coverage and medical directors are expected to exercise clinical judgment for individual coverage determinations.

Listed Products Covered5

Initial/Reauthorization Duration12 months

Age threshold for Emend capsules>=12 years

Guideline version citedNCCN V1.2019 referenced

Recent revisions2 revision events noted

Medical Necessity Criteria

General Medical Necessity

Antiemetic Therapy is considered medically necessary when the following criteria are met:

ALL of the following

Requested product is one of the listed Antiemetic Therapy products (Akynzeo, Anzemet, Emend suspension, Sancuso transdermal, Varubi)
Use corresponds to an FDA approved indication or the coverage criteria specified for each product
Dosage, frequency, duration, and site of care are reasonable and clinically appropriate

Akynzeo (palonosetron/netupitant) capsule – Criteria for Use

ALL of the following

Not Medically Necessary / Experimental Uses

Not Medically Necessary / Experimental

ALL of the following

Antiemetic Therapy is considered experimental, investigational or unproven for ANY other use not specified in criteria

The policy includes selected revisions that removed specific product criteria: removal of Emend capsule medical necessity criteria, and removal of multiple injectable and other formulation criteria including Akynzeo injection, Aloxi injection, Cinvanti injection, Emend injection, Sustol injection, Zofran solution, Zofran tablets, Zofran ODT, and Zuplenz film. The revision notes list associated dates for the selected changes: 01/01/2025 and 05/30/2025, and state that the policy effective date remains in force until updated or retired.

Provider Actions & Administrative Requirements

Documentation Required

Document intolerance to generic aprepitant capsules

For Emend oral suspension coverage in adults (and patients >=12 years), providers must document intolerance or inability to use generic aprepitant capsules.

Documentation Required

Use appropriate dosing regimens

Follow FDA-recommended dosing for Emend suspension in adults and use the weight-based pediatric dosing when applicable, including the recommended dexamethasone dose adjustments when coadministered with Emend.

Coding & Policy Identifiers

Policy Identifiermixed

1705	Coverage Policy Number (Cigna)

Policy identifiers mentioned in this partmixed

Coverage Policy Number: 1705

Cigna internal coverage policy identifier referenced in header/footer of document part

Background and Clinical Guidance

This policy summarizes FDA-approved indications, recommended dosing, drug availability, and professional society (NCCN) guidance for antiemetic agents used for chemotherapy-induced and postoperative nausea and vomiting. FDA indications and dosing details are included for covered products (for example, Akynzeo capsules with dexamethasone for prevention of acute and delayed CINV; Anzemet tablets for prevention of chemotherapy-associated nausea/vomiting; Emend oral suspension for prevention of acute and delayed CINV in patients unable to use capsules, with weight-based pediatric dosing; Sancuso transdermal for prevention in moderately/highly emetogenic regimens; and Varubi for prevention of delayed nausea and vomiting). The document lists product availability (capsule, tablet, suspension, transdermal patch, tablet) and specific dosing guidance (including dexamethasone dose adjustments when coadministered with Emend). NCCN guidance is summarized by emetogenic risk level (high/moderate/low/minimal) and regimen selection recommendations. Importantly, the Coverage Policy reiterates that the customer's benefit plan language controls coverage and that clinical judgment applies to individual coverage decisions.

NCCN-based emetogenic risk recommendations (informational guidance)

Recommended antiemetic regimens by emetogenic risk level (NCCN 2019):

ANY of the following

High IV emetic risk regimens: High emetic risk IV chemotherapy: regimens include either aprepitant (oral or IV), fosaprepitant IV, or rolapitant oral in combination with a 5-HT3 receptor antagonist (palonosetron IV; granisetron SQ, oral, IV or transdermal; or ondansetron oral or IV) with dexamethasone.

Medicare Determinations

Name	Type	Effective Date	Number
Aprepitant for Chemotherapy-Induced Emesis	NCD	2013-05-29

Revision History

01/01/2025Removal

Removed Emend capsule medical necessity criteria from the policy.

05/30/2025RemovalLatest

05/30/2025ClarificationLatest

Policy Summary

PayerCigna

PolicyAntiemetic Therapy

Policy CodePolicy 1705

Change TypeSelected revisions — removals of capsule and multiple injectable criteria

Effective DateMay 30, 2025

Next Review Date

On This Page

Akynzeo is used in combination with dexamethasone

ONE of the following

Prevention of nausea and vomiting for intravenous antineoplastic therapy with high emetic risk
Prevention of nausea and vomiting for intravenous antineoplastic therapy with moderate emetic risk

Anzemet (dolasetron) tablet – Criteria for Use

ALL of the following

Considered medically necessary for prevention of nausea and vomiting and treatment of breakthrough nausea and vomiting associated with low, moderate, and highly emetogenic cancer therapy

Emend (aprepitant) suspension – Criteria for Use (Adults)

ALL of the following

Member is an adult
ANY of the following
- Prevention of nausea and vomiting in combination with dexamethasone and a serotonin (5-HT3) receptor antagonist for IV antineoplastic therapy with high or moderate emetic risk
- Prevention of post-operative nausea and vomiting (PONV) in an adult
Documented intolerance or inability to use generic aprepitant capsules

Emend (aprepitant) suspension – Criteria for Use (Pediatrics)

ALL of the following

Prevention of nausea and vomiting associated with cancer chemotherapy in combination with a serotonin (5-HT3) receptor antagonist
For individuals 12 years of age and older: documented intolerance or inability to use generic aprepitant capsules

Sancuso (granisetron) transdermal – Criteria for Use

ALL of the following

Member is an adult
ANY of the following
- Prevention of nausea and vomiting for high or moderate emetic risk intravenous antineoplastic therapy in combination with dexamethasone
- Prevention of nausea and vomiting for high or moderate emetogenic risk oral antineoplastic therapy
- Breakthrough treatment of chemotherapy-induced nausea/vomiting

Varubi (rolapitant) tablet – Criteria for Use

ALL of the following

Member is an adult
Varubi is used in combination with dexamethasone and a serotonin (5-HT3) receptor antagonist
ANY of the following
- Prevention of nausea and vomiting for intravenous antineoplastic therapy with high emetic risk
- Prevention of nausea and vomiting for intravenous antineoplastic therapy with moderate emetic risk

Duration and Renewal

ALL of the following

Initial and reauthorization coverage up to 12 months

Documentation Required

Follow NCCN emetogenic risk guidance

Document the chemotherapy emetogenic risk level (high/moderate/low/minimal) to support selection of antiemetic regimens consistent with NCCN guidance summarized in this policy.

Billing Rule

Claims must use covered diagnosis/procedure codes

Claims must be submitted with covered diagnosis and/or procedure codes per the policy; services billed without covered codes will be denied as not covered.

Prior Authorization

Policy revisions removed specific injectable and capsule criteria

Policy revisions removed medical necessity criteria for Emend capsule and multiple injectable formulations; ensure prior authorization workflows reflect these listed changes and the associated revision dates.

High IV other options: High emetic risk IV chemotherapy: other options include netupitant/palonosetron oral + dexamethasone; olanzapine oral + palonosetron IV + dexamethasone; or aprepitant (oral) or fosaprepitant IV + 5-HT3 antagonist + dexamethasone + olanzapine.

Moderate IV regimens: Moderate emetic risk IV chemotherapy: options include a 5-HT3 receptor antagonist + dexamethasone; preference for palonosetron IV or granisetron SQ when 5-HT3 not used with an NK1 antagonist; other options include aprepitant (oral/IV), fosaprepitant IV, rolapitant oral + 5-HT3 + dexamethasone; netupitant/palonosetron oral + dexamethasone; or olanzapine oral + palonosetron IV + dexamethasone.

Low/minimal IV: Low emetic risk IV chemotherapy: use dexamethasone; metoclopramide; prochlorperazine; or an oral 5-HT3 receptor antagonist. Minimal emetic risk: no routine prophylaxis.

Oral chemotherapy guidance: Oral chemotherapy: for high to moderate emetogenic risk recommend a 5-HT3 receptor antagonist (granisetron oral or transdermal; or ondansetron oral). For low to minimal risk, treat PRN and escalate subsequent cycles if breakthrough occurs.

Breakthrough CINV: If breakthrough CINV occurs: change antiemetic regimen to a higher level for subsequent chemotherapy cycles.

Pharmacology summary (informational)

ALL of the following

Aprepitant, fosaprepitant, and rolapitant are substance P/NK1 receptor antagonists.
Palonosetron and granisetron are selective 5-HT3 receptor antagonists.
Akynzeo is a combination product of palonosetron (5-HT3) and netupitant (NK1).

TermHigh/Moderate/Low/Minimal emetic risk

High>90% frequency of emesis

Moderate30-90% frequency of emesis

Low10-30% frequency of emesis

Minimal<10% frequency of emesis

Oral agents threshold noteFor oral agents, moderate to high >=30%; minimal/low <30%

Selected Revision 2 dates provided: 01/01/2025 and 05/30/2025 associated with the removals; the policy effective date remains in force until updated or retired.