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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsClover Health Bortezomib Prior Auth | OpenPayer
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    CurrentClover HealthPolicy 3858-A

    Bortezomib (Velcade) Coverage Criteria

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    Medicare Part B coverage and prior authorization for bortezomib (Velcade) for specified hematologic malignancies and related conditions, subject to approval criteria and applicable exclusions.

    Policy Summary
    PayerClover Health
    PolicyBortezomib (Velcade) Coverage Criteria
    Policy CodePolicy 3858-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications not enumerated in the policy.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    21Covered indications
    12 monthsAuthorization period
    Part BBenefit category
    Individual assessmentOther indications
    9Covered-use categories

    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.

    Coverage Criteria

    Covered indications

    Covered when the requested use is an FDA-labeled or recognized compendial indication, all approval criteria are met, and the member has no exclusion to the prescribed therapy.

    Covered bortezomib use

    • Covered indication: Multiple myeloma; mantle cell lymphoma; systemic light chain amyloidosis; anaplastic large cell lymphoma; peripheral T-cell lymphoma not otherwise specified; angioimmunoblastic T-cell lymphoma; enteropathy-associated T-cell lymphoma; monomorphic epitheliotropic intestinal T-cell lymphoma; nodal peripheral T-cell lymphoma with TFH phenotype; follicular T-cell lymphoma; adult T-cell leukemia/lymphoma; Kaposi sarcoma; multicentric Castleman disease; acute lymphoblastic leukemia; mycosis fungoides/Sezary syndrome; Waldenstrom macroglobulinemia/lymphoblastic lymphoma; follicular lymphoma; HIV-related B-cell lymphoma; breast implant associated ALCL; hepatosplenic T-cell lymphoma; or POEMS syndrome.

      Compendial uses must be supported by ICD-10 codes recognized by the Medicare Administrative Contractor.

    • Therapy eligibility: The member has no exclusion to the prescribed therapy.

    Other compendial uses

    Other indications are assessed individually.

    Individual assessment for other indications: The requested indication is not enumerated in the policy and the submission is accompanied by supporting evidence from Medicare-approved compendia.

    The complete list of covered ICD-10 codes is maintained by the Medicare Administrative Contractor.

    Treatment of covered indications

    Authorization may be granted for treatment of a covered indication.

    Covered indication: Acute lymphoblastic leukemia; mycosis fungoides/Sezary syndrome; Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma; follicular lymphoma; HIV-related B-cell lymphoma; breast implant-associated anaplastic large cell lymphoma; hepatosplenic T-cell lymphoma; POEMS syndrome; or another approvable indication listed in LCA A52371.

    Authorization may be granted for 12 months.

    Coverage requires that all approval criteria are met and that the member has no exclusion to the prescribed therapy.

    Authorization and Provider Actions

    Prior Authorization

    Request a 12-month authorization

    Prior authorization may be granted for 12 months when bortezomib is used to treat one of the disease-specific indications addressed in the policy.

    Prior Authorization

    Authorize covered indications for 12 months

    Prior authorization may be granted for 12 months when bortezomib is requested for a covered indication, including hematologic malignancies and other approvable indications described in the policy.

    • Covered examples include acute lymphoblastic leukemia, mycosis fungoides/Sezary syndrome, and Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma.
    Note

    Observe applicable dosing limits

    Clinical Background

    Bortezomib (Velcade) is covered for multiple hematologic malignancies and related conditions, including lymphoid and plasma-cell disorders. Covered uses include multiple myeloma, mantle cell lymphoma, systemic light chain amyloidosis, several T-cell and B-cell lymphomas, acute lymphoblastic leukemia, Kaposi sarcoma, multicentric Castleman disease, and POEMS syndrome—polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes. Other indications may be assessed individually when supported by Medicare-approved compendial evidence.

    Definitions

    POEMS syndrome
    PPolyneuropathy
    OOrganomegaly
    EEndocrinopathy
    MMonoclonal protein
    SSkin changes syndrome
    POEMS syndrome
    PPolyneuropathy
    O

    Initial Therapy Criteria

    Disease-specific 12-month authorization

    Authorization of 12 months may be granted for treatment of a specified covered indication.

    Disease-specific authorization

    • Specified covered indication: Multiple myeloma; mantle cell lymphoma; systemic light chain amyloidosis; anaplastic large cell lymphoma; peripheral T-cell lymphoma not otherwise specified; angioimmunoblastic T-cell lymphoma; enteropathy-associated T-cell lymphoma; monomorphic epitheliotropic intestinal T-cell lymphoma; nodal peripheral T-cell lymphoma with TFH phenotype; follicular T-cell lymphoma; adult T-cell leukemia/lymphoma; Kaposi sarcoma; multicentric Castleman disease; acute lymphoblastic leukemia; mycosis fungoides/Sezary syndrome; Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma; follicular lymphoma; HIV-related B-cell lymphoma; breast implant-associated anaplastic large cell lymphoma; hepatosplenic T-cell lymphoma; or POEMS syndrome.

    Initial authorization for covered indications

    Authorization may be granted for initial treatment of a covered indication.

    Covered indication:
    Policy Summary
    PayerClover Health
    PolicyBortezomib (Velcade) Coverage Criteria
    Policy CodePolicy 3858-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications not enumerated in the policy.
    SourceLink
    On This Page
    Coverage CriteriaAuthorization and Provider ActionsClinical BackgroundDefinitionsInitial Therapy Criteria

    Approved treatment may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

    Documentation Required

    Submit compendial support for other indications

    For indications other than those enumerated in the policy, submit supporting evidence from Medicare-approved compendia for individual assessment.

    • Compendial uses must be supported by ICD-10 codes recognized by the Medicare Administrative Contractor.
    • The complete list of covered ICD-10 codes is maintained by the Medicare Administrative Contractor.
    Denial Risk

    Support unlisted indications

    Coverage may be denied when the requested use is not one of the listed FDA-labeled or recognized compendial indications unless the submission includes supporting evidence from Medicare-approved compendia for individual assessment.

    Denial Risk

    Meet all criteria and verify exclusions

    Coverage requires that all approval criteria be met and that the member have no exclusions to the prescribed therapy.

    • Verify that the requested use meets the applicable approval criteria.
    • Confirm that the member has no exclusion to the prescribed therapy.
    Organomegaly
    EEndocrinopathy
    MMonoclinal protein
    SSkin changes syndrome
    The requested treatment is for acute lymphoblastic leukemia, mycosis fungoides/Sezary syndrome, Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma, follicular lymphoma, HIV-related B-cell lymphoma, breast implant-associated anaplastic large cell lymphoma, hepatosplenic T-cell lymphoma, POEMS syndrome, or another approvable indication listed in LCA A52371.

    Authorization may be granted for 12 months.