CurrentCommunity-CarePolicy N/A

Sylvant

This policy defines coverage criteria, laboratory thresholds, dosing rounding, continuation criteria, quantity limits, authorization period, and applicable billing code for siltuximab (Sylvant) when used to treat multicentric Castleman disease (MCD)/iMCD.

Policy Summary

PayerCommunity-Care

PolicySylvant

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionSubmit documentation confirming MCD diagnosis per CDCN criteria, weight for dosing, and required lab results; include specialist consultation notes and clinical rationale if eligible dose is not rounded down.

SourceLink

POLICY UPDATE CHANGES

Document includes dose rounding requirement and necessity for clinical rationale if eligible dose is not rounded down.

1Covered Indications (MCD)

1 yrAuthorization Period

J2860Primary HCPCS Code

Coverage Summary

Coverage for siltuximab (Sylvant) is covered with criteria for treatment of multicentric Castleman disease (MCD). The policy requires that the drug be prescribed by or in consultation with a hematologist or oncologist and that the diagnosis meet CDCN diagnostic criteria (lymph node biopsy characteristic of MCD, enlarged lymph nodes in ≥ 2 stations on CT/PET, and at least 2 minor CDCN criteria including ≥1 laboratory criterion). Prior to the first dose the policy requires laboratory thresholds including ANC ≥ 1.0 x 10^9/L, platelets ≥ 75 x 10^9/L, and hemoglobin < 17 g/dL. Dose rounding to the nearest vial is required when within 10% of a vial and specialist involvement and documented labs are required for approval.