CurrentClover HealthPolicy 5133-A

Jurisdiction Specific Medicare Part B Camcevi

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This policy governs prior authorization and coverage of Camcevi, including brand and generic products and all dosage forms and strengths, for Medicare Part B members in specified jurisdictions. Coverage applies to prostate cancer, certain salivary gland tumors, and other approvable indications when the stated approval criteria and applicable exclusions are satisfied.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Camcevi

Policy CodePolicy 5133-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization documentation showing that the member meets the applicable criteria for the requested indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsAuthorization duration for approved indications

9Explicitly identified covered jurisdictions

2Named product names covered

2Explicitly named disease indications

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CurrentClover HealthPolicy 5133-A

Jurisdiction Specific Medicare Part B Camcevi

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Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Camcevi

Policy CodePolicy 5133-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization documentation showing that the member meets the applicable criteria for the requested indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsAuthorization duration for approved indications

9Explicitly identified covered jurisdictions

2Named product names covered

2Explicitly named disease indications

Prostate Cancer

Authorization of 12 months may be granted when the member is being treated for prostate cancer.

Prostate cancer: Treatment of prostate cancer

Authorization duration is 12 months.

Salivary Gland Tumor

Authorization of 12 months may be granted when all applicable criteria are met.

Salivary gland tumor

Disease status: The salivary gland tumor is recurrent, unresectable, or metastatic.
Androgen receptor status and regimen: The tumor is androgen receptor positive and treatment is administered either as a single agent or in combination with abiraterone and prednisone.

All Other Indications

Authorization of 12 months may be granted for other approvable indications.

Other approvable indications: The indication is an approvable indication listed in LCA A52453.

Authorization duration is 12 months.

Coverage is not available when the member has an exclusion to the prescribed therapy.

Compendial Uses and Supported Codes

Compendial Uses - ICD-10 codes supported by the Medicare Administrative ContractorICD-10

ICD-10

The list of covered ICD-10 codes is maintained by the Medicare Administrative Contractor; a complete list is available from the CMS Medicare Coverage Database indexes.

Authorization and Documentation Requirements

Prior Authorization

12-month authorization

Prior authorization may be granted for 12 months when the member meets the applicable indication-specific coverage criteria for prostate cancer, salivary gland tumor, or another approvable indication listed in LCA A52453.

Documentation Required

Submit compendial support for other indications

For indications other than those listed in the policy criteria, submit supporting evidence from Medicare-approved compendia.

Denial Risk

Avoid noncovered indications and unmet criteria

Coverage may be denied when the prescribed indication is not a covered FDA-labeled or recognized compendial use, when approval criteria are not met, or when the member has an exclusion to the prescribed therapy.

Documentation Required

Support other indications with compendial evidence

Indications other than those listed in the policy are assessed individually. Submissions for these indications should be accompanied by supporting evidence from Medicare-approved compendia.

Medication and Coverage Overview

Camcevi (leuprolide mesylate) is a luteinizing hormone-releasing hormone analog covered under this Medicare Part B policy when applicable approval criteria are met. Covered uses include treatment of prostate cancer and specified salivary gland tumors, including recurrent, unresectable, or metastatic tumors that are androgen receptor positive and treated either as a single agent or with abiraterone and prednisone. Other FDA-labeled or Medicare-approved compendial uses may also be considered under the policy.

Compendial Uses

Compendial uses

DefinitionCompendial uses are recognized off-label uses identified in Medicare-approved compendia, in addition to FDA-labeled indications.

FDA-labeled indicationsFDA-approved indications are included among the covered uses when all approval criteria are met and the member has no exclusion to the prescribed therapy.

ICD-10 supportCovered ICD-10 codes for compendial uses are supported by the applicable Medicare Administrative Contractor.

Code listThe complete list of covered ICD-10 codes is maintained externally by the Centers for Medicare & Medicaid Services because it is too extensive to reproduce in the policy.

Other indicationsIndications outside those listed in the policy are assessed individually and should be submitted with supporting evidence from Medicare-approved compendia.

Indication-Specific Initial Therapy Criteria

Prostate Cancer

Authorization of 12 months may be granted for treatment of prostate cancer.

Prostate cancer initial authorization: Member is being treated for prostate cancer.

Authorization duration is 12 months.

Salivary Gland Tumor

Authorization of 12 months may be granted for treatment of a qualifying salivary gland tumor.

Qualifying salivary gland tumor: Member has recurrent, unresectable, or metastatic salivary gland tumor that is androgen receptor positive; Camcevi is used as a single agent or with abiraterone and prednisone.

Authorization duration is 12 months.

All Other Approvable Indications

Authorization of 12 months may be granted for other approvable indications.

LCA A52453 indication: The requested use is an approvable indication listed in LCA A52453.

Authorization duration is 12 months.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Camcevi

Policy CodePolicy 5133-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization documentation showing that the member meets the applicable criteria for the requested indication.

SourceLink

On This Page

Jurisdiction Specific Medicare Part B Camcevi

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Jurisdiction Specific Medicare Part B Camcevi

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Covered Indications and Exclusions

Compendial Uses and Supported Codes

Authorization and Documentation Requirements

Medication and Coverage Overview

Compendial Uses

Indication-Specific Initial Therapy Criteria