CurrentMVP Health CarePolicy N/A

Doh 2022 Avastin

Defines MVP Health Care Medicaid medical policy for bevacizumab (Avastin) including applicable codes, administration codes, coverage stance for on-label and off-label uses, prior authorization requirements, and relation to MVP programs/policies.

Policy Summary

PayerMVP Health Care

PolicyDoh 2022 Avastin

Policy CodePolicy N/A

Change Typeclarified

Effective Date04/01/2025

Next Review Date

Key ActionAvastin when used for a cancer diagnosis requires prior authorization per the MVP Cancer Guidance Program.

SourceLink

POLICY UPDATE CHANGES

Prior Approval Date listed as 11/01/2023; Approval Date 02/01/2025; Effective Date 04/01/2025.

1Primary HCPCS drug code listed

3Administration CPT codes listed

On-label coveredOn-label coverage stance

Off-label requires PAOff-label coverage stance

Coverage Summary & Criteria

Coverage is mixed: on‑label oncology uses of Avastin (bevacizumab) are covered under the member's medical benefit but are subject to retro‑review; cancer indications require prior authorization per the MVP Cancer Guidance Program. Off‑label ophthalmic uses (compendia‑supported indications such as diabetic macular edema, diabetic retinopathy, and macular degeneration) are recognized in compendia but are subject to prior authorization and must meet MVP clinical coverage criteria for Experimental/Investigational Procedures, Behavioral Health Services, Drugs and Treatments, Off‑Label use of FDA‑Approved Drugs, and Clinical Trials Policy.

Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

On-label use of Avastin (bevacizumab) is covered under the member's medical benefit
Coverage is subject to retro-review
Cancer diagnosis PA: Avastin used for a cancer diagnosis is subject to prior authorization per the MVP Cancer Guidance Program
Prior authorization required
Off-label use
- Referenced MVP policies: Off-label use must meet MVP clinical coverage criteria for Experimental or Investigational Procedures, Behavioral Health Services, Drugs and Treatments, Off-Label use of FDA Approved Drugs, and Clinical Trials Policy

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Prior Authorization, Documentation & Billing Impact

Prior Authorization

Prior authorization for cancer indications

Avastin (bevacizumab) when used for a cancer diagnosis requires prior authorization per the MVP Cancer Guidance Program.

Affected codes: ["J9035"]
Reference: MVP Cancer Guidance Program

Prior Authorization

Prior authorization for off-label use

Off-label uses of Avastin require prior authorization and must meet MVP's clinical coverage criteria for Experimental or Investigational Procedures, Behavioral Health Services, Drugs and Treatments, Off-Label use of FDA Approved Drugs, and Clinical Trials Policy.

Affected codes: ["J9035"]
Referenced MVP policies: Experimental or Investigational Procedures; Behavioral Health Services; Drugs and Treatments; Off-Label use of FDA Approved Drugs; Clinical Trials Policy

Documentation Required

Retro-review for on-label use

On-label use of Avastin is covered but is subject to post-service retro-review; providers should retain clinical documentation to support on-label administration and billing.

Affected codes: ["J9035"]
Retain clinical documentation for retro-review

Relevant Codes

Medical benefit drug codeHCPCSCovered

J9035

Injection, bevacizumab, 10 mg

Administration codesCPT

96413	Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
96415	Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure). Use 96415 in conjunction with 96413.
67028	Intravitreal injection of a pharmacologic agent (separate procedure)

Billing note: the primary HCPCS drug code listed is J9035 (injection, bevacizumab, 10 mg). Administration CPT codes are listed but treated as neutral (96413, 96415, 67028). Prior authorization requirements described under Provider Actions apply to J9035 for cancer indications and for off‑label uses.

Background & Evidence

Avastin (bevacizumab) is a vascular endothelial growth factor (VEGF)‑directed monoclonal antibody. It is indicated for multiple cancers including cervical cancer, colorectal cancer, glioblastoma multiforme, non‑small cell lung cancer (NSCLC), ovarian cancer, and renal cell cancer. The policy notes compendia‑supported off‑label ophthalmic uses for diabetic macular edema, diabetic retinopathy, and macular degeneration.

Relation to MVP policies: on‑label cancer uses are covered but subject to retro‑review and cancer‑specific prior authorization; off‑label uses require prior authorization and must satisfy MVP clinical coverage criteria referenced in related policies for Experimental or Investigational Procedures, Behavioral Health Services, Drugs and Treatments, Off‑Label use of FDA‑Approved Drugs, and Clinical Trials Policy.

Source	Reference
Prescribing information	Avastin [prescribing information], Genentech, Inc., September 2022

Revision History

2023-11-01prior_approval_date

Prior Approval Date listed as 11/01/2023; Administrative dates provided in header; no clinical policy statement changes indicated.

2025-02-01approval_date

Approval Date listed as 02/01/2025; Administrative dates provided in header; no clinical policy statement changes indicated.

2025-04-01effective_dateLatest

Effective Date listed as 04/01/2025; Administrative dates provided in header; no clinical policy statement changes indicated.

OpenPayer