CurrentEmblemHealthPolicy MG.MM.PH.181

Zevalin Y-90 (ibritumomab tiuxetan) Intravenous

Covers medical necessity criteria, dosing, coding, and limitations for Zevalin (ibritumomab tiuxetan Y-90) therapy for follicular and low-grade B-cell non-Hodgkin lymphoma for EmblemHealth members.

Policy Summary

PayerEmblemHealth

PolicyZevalin Y-90 (ibritumomab tiuxetan) Intravenous

Policy CodePolicy MG.MM.PH.181

Change TypeNo material changes

Effective Date

Next Review DateJan 2, 2025

Key ActionSubmit clinical evidence to EmblemHealth for prior authorization demonstrating the member meets medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 treatmentlength of authorization

≤32 mCimax Y-90 activity

<26%max marrow involvement

≥100k/mm3min platelets

A9543procedure code

Coverage and Medical Necessity Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Approval Criteria

Covered when ALL of the following are met:

Indication: Patient has documented relapsed or refractory low-grade or follicular B-cell non-Hodgkin's lymphoma OR previously untreated follicular non-Hodgkin lymphoma who achieved a partial or complete response to first-line chemotherapy.

(see chunks 6)

Bone marrow involvement is less than 26 percent.<26%

(chunk 7)

Platelet count is 100,000 cells/mm3 or greater.>=100,000/mm3

(chunk 7)

Timing for untreated patients: For previously untreated follicular NHL, therapy must be initiated at least 6 weeks but no more than 12 weeks following the last dose of first-line chemotherapy.6-12 weeks

(chunk 7)

Coverage is limited by specific age, radiation dose, and bone marrow/platelet requirements. Zevalin is not appropriate for pediatric patients under 18 years of age. The policy sets a maximum administered activity of 32 mCi (1184 MBq) of Y-90 per treatment and excludes patients with significant marrow involvement or impaired marrow reserve. Specifically, therapy is excluded for patients with ≥25% bone marrow involvement or otherwise impaired bone marrow reserve. A minimum platelet count of 100,000 cells/mm3 is required; patients with platelet counts below this threshold are not eligible.

Zevalin is considered not medically necessary when any exclusion below is met: patient age <18 years; total Y-90 activity would exceed 32 mCi (1184 MBq); bone marrow involvement is ≥25% or there is impaired bone marrow reserve; or platelet count is 100,000 cells/mm3.

Dosing, Administration and Regimen Details

Component	Details
Rituximab pre-dose
Day 1: rituximab 250 mg/m2 IV; premedicate with acetaminophen 650 mg PO and diphenhydramine 50 mg
Second rituximab dose and Y-90 timing
Day 7, 8, or 9: infuse rituximab 250 mg/m2 IV; administer Y-90 ibritumomab tiuxetan IV within 4 hours after rituximab infusion on Day 7, 8, or 9
Platelet-stratified Y-90 dosing
If platelets >150,000/mm3: 0.4 mCi/kg (14.8 MBq/kg); if platelets 100,000–149,000/mm3: 0.3 mCi/kg (11.1 MBq/kg)
Platelet requirement
>= 100,000 cells/mm3 required prior to treatment
Maximum Y-90 activity
Do not exceed 32 mCi (1184 MBq) per policy (see limitations)
Bone marrow involvement
Bone marrow involvement must be <26% prior to treatment
Premedication
Premedicate with acetaminophen 650 mg PO and diphenhydramine 50 mg prior to rituximab infusions

second-line | consolidation

Line of therapy: Relapsed/refractory (salvage) therapy OR consolidation therapy after response to first-line chemotherapy for previously untreated follicular NHL.

(chunks 6,10)

Procedure, Drug and Diagnosis Codes; Lab Thresholds

Applicable Procedure CodesHCPCSCovered

A9543

Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries

Applicable NDCsNDC

72893-0007-xx

Zevalin 3.2 mg per 2 mL single-use vial

Applicable ICD-10 DiagnosesICD-10

C82.00-C82.99	Follicular lymphoma
C83.00-C83.09	Lymphosarcoma and reticulosarcoma, other named variants
C83.30-C83.39	Lymphosarcoma and reticulosarcoma, other named variants
C83.90-C83.99	Lymphosarcoma and reticulosarcoma, other named variants
C86.5-C86.6	Lymphosarcoma and reticulosarcoma, other named variants
C84.10-C84.99	Cutaneous T-cell and mature T/NK-cell lymphomas
C88.4	Marginal zone lymphoma [gastric/nongastric MALT, primary cutaneous B-cell lymphoma]

inv-07: Platelet count — dosing stratified by platelet thresholds (value and dosing mapping)

Minimum platelet requirementPlatelet count must be ≥100,000 cells/mm3

Dosing if platelets >150,000/mm3Administer 0.4 mCi/kg (14.8 MBq/kg) Y-90 Zevalin IV within 4 hours after rituximab infusion

Dosing if platelets 100,000–149,000/mm3Administer 0.3 mCi/kg (11.1 MBq/kg) Y-90 Zevalin IV within 4 hours after rituximab infusion

inv-08: Bone marrow involvement — marrow involvement threshold

Maximum allowed bone marrow involvementBone marrow involvement must be less than 26%

Exclusion threshold noted elsewherePatients with ≥25% bone marrow involvement and/or impaired bone marrow reserve are listed in exclusions

inv-09: Maximum Y-90 activity — do not exceed 32 mCi (1184 MBq)

Maximum Y-90 activity per policyDo not exceed 32 mCi (1184 MBq)

Related exclusionExceeding 32 mCi is listed as a limitation/exclusion to medical necessity

Authorization, Documentation and Submission Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for Zevalin (HCPCS A9543); requests will be reviewed against the medical necessity criteria listed and supporting documentation must be submitted to EmblemHealth for review.

Applicable procedure code: A9543

Step Therapy

Post–first-line response required for untreated patients

For previously untreated follicular NHL, Zevalin is indicated only for patients who achieve a partial or complete response to first-line chemotherapy and therapy must be initiated 6–12 weeks after the last dose of first-line chemotherapy.

Therapy initiation window: at least 6 weeks but no more than 12 weeks following last dose of first-line chemotherapy

Documentation Required

Clinical evidence submission

The treating physician must submit clinical evidence to EmblemHealth that the member meets the criteria for treatment to obtain preauthorization or for post-payment review.

Submit clinical evidence demonstrating the member meets the policy criteria.

Denial Risk

Documentation submission required

Failure to provide the required clinical documentation will prevent EmblemHealth from properly reviewing the preauthorization request or post-payment review and may result in denial.

Lack of submitted clinical evidence/documentation may result in denial of the request.

Background and Drug Overview

Zevalin (ibritumomab tiuxetan) is a CD20-targeting monoclonal antibody conjugated to radioactive Yttrium-90 for radioimmunotherapy of B‑cell non‑Hodgkin lymphomas. It is used in relapsed or refractory low‑grade or follicular B‑cell NHL and as consolidation in previously untreated follicular NHL after response to first‑line chemotherapy; administration involves a radiolabeled ibritumomab dose using Y‑90 emissions to produce targeted tumor cell cytotoxicity.

Key Definitions

inv-15: Zevalin (ibritumomab tiuxetan) — definition and mechanism

Agent identityZevalin (ibritumomab tiuxetan): a monoclonal antibody linked to Yttrium-90 (Y-90)

Target and bindingIbritumomab binds specifically to the CD20 antigen on pre-B and mature B lymphocytes and >90% of B-cell NHL

Chelator and radionuclideThe tiuxetan chelate is covalently linked to ibritumomab and tightly binds Y-90

Mechanism of actionBeta emissions from Y-90 induce cellular damage via formation of free radicals in target and neighboring cells

Policy Summary

PayerEmblemHealth

PolicyZevalin Y-90 (ibritumomab tiuxetan) Intravenous

Policy CodePolicy MG.MM.PH.181

Change TypeNo material changes

Effective Date

Next Review DateJan 2, 2025

Key ActionSubmit clinical evidence to EmblemHealth for prior authorization demonstrating the member meets medical necessity criteria.

SourceLink

On This Page