CurrentEmblemHealthPolicy MG.MM.PH.153

Ixempra® (ixabepilone) Intravenous

Policy governing medical necessity, initial and renewal coverage criteria, dosing, limits, applicable procedure/NDC/ICD-10 codes, and exclusions for intravenous Ixempra (ixabepilone) for EmblemHealth/ConnectiCare members.

Policy Summary

PayerEmblemHealth

PolicyIxempra® (ixabepilone) Intravenous

Policy CodePolicy MG.MM.PH.153

Change TypeAnnual reviewremoved trastuzumab-related criteria

Effective DateMar 31, 2025

Next Review Date

Key ActionTreating physician must submit clinical evidence that member meets criteria for treatment; without documentation EmblemHealth will not properly review the request (preauthorization or post-payment).

SourceLink

POLICY UPDATE CHANGES

03/31/2025 Annual Review: No criteria changes.

02/16/2024 Annual Review: Removed prior specific trastuzumab-related breast cancer criteria.

07/25/2022 Transferred policy to new template and updated billing codes.

1Covered Indications (breast cancer)

40 mg/m2Single dose limit

90Max units per 21 days

6 monthsInitial authorization length

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Coverage Summary & Scope

ref b0_0: Policy Number MG.MM.PH.153; Subject: Ixempra (ixabepilone) intravenous; Status: CURRENT; Effective/Last Review Date: 03/31/2025. Scope: Policy governing medical necessity, initial and renewal coverage criteria, dosing, limits, applicable procedure/NDC/ICD-10 codes, and exclusions for intravenous Ixempra (ixabepilone) for EmblemHealth/ConnectiCare members. Background: Ixabepilone is indicated for specific recurrent or metastatic breast cancer situations with defined initial approval, renewal, and exclusion criteria.

Quick Policy Facts and Thresholds

Length of Authorization6 months (may be renewed)

Max Units90 billable units per 21 days

Single Dose Limit40 mg/m2

Initial authorization length6 months

Covered Indications (count)1 (Breast cancer)

Initial Approval Criteria

Renewal / Continuation Criteria

Renewal Criteria

Coverage may be renewed when ALL of the following are met:

ALL of the following

Patient continues to meet INITIAL APPROVAL CRITERIA.
Tumor response with stabilization of disease or decrease in size of tumor or tumor spread.
Absence of unacceptable toxicity from the drug including peripheral neuropathy, myelosuppression, hepatic impairment, hypersensitivity reactions, impaired cardiac function, cardiac ischemia.

Limitations and Exclusions (Not Medically Necessary)

Limitations / Exclusions (Not Medically Necessary)

Ixempra (ixabepilone) is not considered medically necessary when ANY of the following selection criteria is met:

ANY of the following

Ixempra is being used as adjuvant chemotherapy.
Dosing exceeds single dose limit of 40 mg/m2 of Ixempra.40 mg/m2
Use in combination with capecitabine when patient has AST or ALT greater than 2.5 times ULN or bilirubin greater than 1 times ULN due to increased risk of toxicity and neutropenia-related death.AST or ALT > 2.5 x ULN; bilirubin > 1 x ULN

Applicable Codes

Applicable HCPCS (drug J-code)HCPCSCovered

J9207

Injection, ixabepilone, 1 mg, 1 billable unit = 1 mg

Applicable NDCsNDCCovered

70020-1910-xx	Ixempra 15 mg powder for injection
70020-1911-xx	Ixempra 45 mg powder for injection

Applicable ICD-10 Diagnoses (Breast cancer / history)ICD-10Covered

C50.011	Malignant neoplasm of nipple and areola, right female breast
C50.012	Malignant neoplasm of nipple and areola, left female breast
C50.019	Malignant neoplasm of nipple and areola, unspecified female breast
C50.021	Malignant neoplasm of nipple and areola, right male breast
C50.022	Malignant neoplasm of nipple and areola, left male breast
C50.029	Malignant neoplasm of nipple and areola, unspecified male breast
C50.111	Malignant neoplasm of central portion of right female breast
C50.112	Malignant neoplasm of central portion of left female breast
C50.119	Malignant neoplasm of central portion of unspecified female breast
C50.121	Malignant neoplasm of central portion of right male breast

1–10 of 55

1/6

Provider Actions & Billing

Prior Authorization

Submit clinical evidence for preauthorization

Treating physician must submit clinical evidence that member meets criteria for treatment; without documentation EmblemHealth will not properly review the request (preauthorization or post-payment).

Preauthorization or post-payment review requires supporting clinical documentation

Billing Rule

Billing units per J9207

Report J9207 units corresponding to mg of ixabepilone (1 billable unit = 1 mg); adhere to max of 90 billable units per 21 days.

J9207 — 1 unit = 1 mg
Max 90 billable units per 21 days

Background and Definitions

ref b6_0: Background: Ixabepilone is a semisynthetic epothilone B analog that stabilizes microtubules, causes G2/M arrest and apoptosis, has antiangiogenic activity, and shows low susceptibility to common tumor resistance mechanisms such as efflux transporters (MRP-1 and P-glycoprotein). Definition: Ixempra (ixabepilone) — semisynthetic analog of epothilone B; microtubule stabilizing cytotoxic agent.

ref b6_1: References: Prescribing information (Bristol-Myers), Clinical Pharmacology, Micromedex, NCCN, AHFS.

Revision History

03/31/2025annual_reviewLatest

Annual Review: No criteria changes.

02/16/2024criteria_removed

Annual Review: Removed prior specific trastuzumab-related breast cancer criteria.

07/25/2022administrative

Transferred policy to new template and updated billing codes.