CurrentCignaPolicy IP0320

Imbruvica for Non-Oncology Uses

Defines Cigna's prior authorization and medical necessity criteria for Imbruvica (ibrutinib) when used for non-oncology indications, specifically chronic graft-versus-host disease (cGVHD) in patients ≥1 year; excludes other non-oncology uses.

Policy Summary

PayerCigna

PolicyImbruvica for Non-Oncology Uses

Policy CodePolicy IP0320

Change TypeRevised criteria and added examples

Effective DateSep 1, 2025

Next Review Date

Key ActionPrior Authorization is required for Imbruvica; approve for 1 year for cGVHD when criteria are met and document prior systemic therapy.

SourceLink

POLICY UPDATE CHANGES

Updated cGVHD criterion wording from 'inadequate response..unless contraindicated or intolerant' to 'tried'.

Added examples of systemic medications (Rezurock, Niktimvo, hydroxychloroquine, rituximab, pentostatin, interleukin-2, cyclosporine, tacrolimus, sirolimus, etanercept product).

Updated policy title from 'Ibrutinib for Non-Oncology Uses' to 'Imbruvica for Non-Oncology Uses'.

1Covered Indications (non-oncology)

1 yearInitial Approval Duration for cGVHD

manyExample systemic medications listed

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Defines Cigna prior authorization and medical necessity criteria for Imbruvica (ibrutinib) when used for non-oncology indications, specifically chronic graft‑versus‑host disease (cGVHD) in patients ≥ 1 year; excludes other non‑oncology uses. Coverage stance: covered_with_criteria.

Policy metadata

Policy numberIP0320

Effective date2025-09-01

Last review2025-09-01

Next review

StatusCURRENT

Initial approval duration1 year

Initial Therapy Criteria (cGVHD)

FDA-Approved Indication - Chronic Graft-Versus-Host Disease (cGVHD)

Prior authorization required. Approve for 1 year if the patient meets BOTH of the following (A and B):

ALL of the following

A: Patient is ≥ 1 year of age
B: Patient has tried at least one systemic medication for graft-versus-host disease
See examples list for acceptable systemic medications

Examples include corticosteroids (methylprednisolone, prednisone), imatinib, low-dose methotrexate, sirolimus, mycophenolate mofetil, ruxolitinib (Jakafi), belumosudil (Rezurock), axatilimab-csfr (Niktimvo), hydroxychloroquine, rituximab, pentostatin, interleukin-2 (e.g., Proleukin), cyclosporine, tacrolimus, and an etanercept product.

Provider Actions

Prior Authorization

Prior authorization required

Prior Authorization is required for benefit coverage of Imbruvica; approvals are provided for the duration noted (approve for 1 year for cGVHD when criteria met).

Approve for 1 year for cGVHD when criteria met

Documentation Required

Document prior systemic therapy for cGVHD

Provider must document that the patient has tried at least one systemic medication for graft-versus-host disease; examples provided in policy should be referenced in the record.

Document examples/definitions of systemic medications (see policy examples list) in the patient record

Billing Rule

Use appropriate codes

Reimbursement is provided only if requested service is submitted with covered diagnosis and/or procedure code(s); providers must use the most appropriate codes as of the effective date.

Submit covered diagnosis/procedure code(s) and use codes effective on the policy effective date

Revision History

2025-09-01title_changeLatest

Updated policy title from 'Ibrutinib for Non-Oncology Uses' to 'Imbruvica for Non-Oncology Uses'.

2024-09-15material_change

Reworded requirement that the patient has tried at least 'one conventional systemic treatment' to 'one systemic medication for graft-versus-host disease'; updated cGVHD criterion wording from 'inadequate response..unless contraindicated or intolerant' to 'tried'.

2025-09-01material_change

Expanded list of acceptable systemic therapies in the Note for criterion B: added examples including Rezurock (belumosudil), Niktimvo (axatilimab‑csfr), hydroxychloroquine, rituximab, pentostatin, interleukin-2 (e.g., Proleukin), cyclosporine, tacrolimus, sirolimus, and an etanercept product.

Policy Summary

PayerCigna

PolicyImbruvica for Non-Oncology Uses

Policy CodePolicy IP0320

Change TypeRevised criteria and added examples

Effective DateSep 1, 2025

Next Review Date

Key ActionPrior Authorization is required for Imbruvica; approve for 1 year for cGVHD when criteria are met and document prior systemic therapy.

SourceLink

On This Page

OpenPayer

Imbruvica for Non-Oncology Uses

Coverage Summary

Initial Therapy Criteria (cGVHD)

Continuation Therapy Criteria

Not Covered / Exclusions

Applicable Codes

Provider Actions

Clinical Evidence & References

Background

Revision History