Bevacizumab (Avastin) medical benefit coverage — Coverage Criteria
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Defines MVP Health Care Medicaid coverage, coding, and authorization rules for bevacizumab (Avastin) when billed under the medical benefit, including on-label and off-label uses and related administration codes.
No material clinical or coverage changes in this revision.
Coverage Criteria and Policy Scope
General Coverage Conditions
Covered when ALL of the following conditions are met:
On-label uses are subject to retro-review
Compendia-supported ophthalmic uses are mentioned in the overview but still require prior authorization
Cancer cases require prior authorization in addition to general coverage policies
Off-label uses of Avastin (bevacizumab) that do not meet MVP Health Care's referenced clinical coverage criteria are excluded from coverage. Specifically, uses that fail to satisfy the requirements in MVP’s policies for Experimental or Investigational Procedures, Drugs and Treatments, Off-Label use of FDA Approved Drugs, or related clinical trial policies will not be covered.
Any use of Avastin that does not meet the referenced clinical coverage criteria is excluded from coverage. Off-label indications require prior authorization and must comply with MVP’s policies for Experimental or Investigational Procedures, Drugs and Treatments, Off-Label use of FDA Approved Drugs, and Clinical Trials; cancer diagnoses using Avastin additionally require prior authorization under the MVP Cancer Guidance Program.
Billing and Coding
| J9035 | Injection, bevacizumab, 10 mg |
| 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) |
| 67028 | Intravitreal injection of a pharmacologic agent (separate procedure) |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required for off‑label and cancer uses
Prior authorization is required for all off‑label uses of bevacizumab (Avastin) and must meet MVP's clinical coverage criteria. Additionally, Avastin used for a cancer diagnosis is subject to prior authorization under the MVP Cancer Guidance Program.
- PA required for off‑label uses and must satisfy MVP policies for Experimental or Investigational Procedures; Drugs and Treatments; Off‑Label use of FDA Approved Drugs; and Clinical Trials.
- Cancer diagnoses require PA per the MVP Cancer Guidance Program.
On‑label coverage is covered but subject to retro‑review
On‑label bevacizumab is covered under the member's medical benefit but is subject to retrospective review; providers should bill under the medical benefit and maintain documentation to support coverage.
- On‑label use: covered under the member's medical benefit and subject to retro‑review.
Documentation must support indication and PA requirements
Documentation must support the on‑label indication when billed under the medical benefit; for off‑label uses, documentation must satisfy prior authorization requirements demonstrating conformity with MVP clinical coverage criteria.
- Keep clinical records that substantiate the indicated diagnosis and medical necessity for on‑label claims (subject to retro‑review).
- For off‑label requests, include documentation required for PA that demonstrates compliance with MVP policies for Experimental or Investigational Procedures; Drugs and Treatments; Off‑Label use of FDA Approved Drugs; and Clinical Trials.
Off‑label uses that fail criteria may be denied
Off‑label uses that do not meet MVP's referenced clinical coverage criteria may be denied as not covered or not medically necessary.
- Denials may be issued if off‑label use fails to meet MVP policies for Experimental or Investigational Procedures; Drugs and Treatments; Off‑Label use of FDA Approved Drugs; or Clinical Trials.
Background and Clinical Context
Bevacizumab (Avastin) is a vascular endothelial growth factor (VEGF)-directed monoclonal antibody that inhibits angiogenesis. It is approved for multiple cancer indications (for example, colorectal, non–small cell lung, ovarian, renal cell carcinoma, cervical cancer, and glioblastoma) and is also used off-label in ophthalmic conditions. Although compendia-supported ophthalmic uses (such as diabetic macular edema, diabetic retinopathy, and age-related macular degeneration) are recognized in the clinical overview, these off-label ophthalmic and other non–FDA-approved indications still require prior authorization and must meet MVP’s clinical coverage criteria.
Definitions
Site of Care and Administration Settings
Use appropriate administration codes for infusion and intravitreal injections
Use the administration code that corresponds to the setting: chemotherapy infusion codes for IV infusion and CPT 67028 for intravitreal injection.
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