Medical Policy: Bevacizumab Intravenous
Defines medical necessity criteria, dosing limits, authorization length, renewal criteria, applicable HCPCS/J-codes, NDCs, and a large list of covered ICD-10 cancer diagnoses for bevacizumab (Avastin, Alymsys, Mvasi, Vegzelma, Zirabev) for Commercial, Medicaid, and Medicare members (Medicare has separate LCD/NCD reference).
Annual Review combined Mvasi/Zirabev policy into Bevacizumab; updated dosage limits and added Medicare LCD/NCD note.
Hepatocellular carcinoma criteria reworded to clarify first-line use with atezolizumab and expanded alternative liver-confined/inoperable scenarios with Child-Pugh A or B.
Colorectal cancer criteria extensively revised to remove adjuvant use and add detailed regimen- and biomarker-specific pathways including use with trifluridine/tipiracil after multiple prior regimens.
NSCLC criteria removed ECOG 0-2 requirement and added numerous molecular biomarker-specific combinations including EGFR exon 19/21 with erlotinib and other mutation contexts.
Cervical cancer criteria updated to permit combinations with pembrolizumab and require PD-L1 CPS ≥1 for that combination; allows single-agent subsequent use and use in NECC.
Multiple indication-specific additions (e.g., ovarian maintenance with olaparib/niraparib combinations, mesothelioma first-line pemetrexed+platinum combinations) and removals (e.g., breast cancer and Kaposi sarcoma removed).
Initial approval criteria updated to require oncologist prescribing/consultation and step therapy applies to new starts only.
Added many ICD-10 diagnosis codes and extensive revision history entries spanning 2019-2024.