Sierra Health and Life antiemetics Coverage Update

Coverage Criteria and Medical Necessity

Diagnosis-Specific Medical Necessity Criteria

Antiemetics are proven and medically necessary when the following criteria (specific to agent class) are met.

NK1 RA (Emend, Cinvanti, Varubi): Covered when ANY of the following are met:

NK1 RA - high emetic risk: Prevention of chemotherapy-induced nausea and vomiting due to High Emetic Risk parenteral anticancer agents

AND in combination with a 5HT3 RA

NK1 RA - moderate emetic risk + risk factors: Prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents

AND in combination with a 5HT3 RA AND presence of one or more risk factors (younger age <55, female sex, prior CINV, little or no previous alcohol use, history of motion sickness or morning sickness, high anxiety)

5HT3 RA (Aloxi, Kytril, Sustol, Zofran): Covered when ANY of the following are met:

5HT3 RA - high emetic risk: Prevention of chemotherapy-induced nausea and vomiting due to High Emetic Risk parenteral anticancer agents

AND in combination with an NK1 RA

5HT3 RA - moderate emetic risk: Prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents

OR when used in combination with an NK1 RA plus at least one risk factor as listed

5HT3 RA - breakthrough: Treatment of breakthrough nausea and/or vomiting due to anticancer agent(s)

NK1 RA/5HT3 RA combination (Akynzeo): Covered when ANY of the following are met:

Combination - moderate emetic risk + risk factors: Prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents

AND presence of one or more risk factors (younger age <55, female sex, prior CINV, little or no previous alcohol use, history of motion sickness or morning sickness, high anxiety)

Combination - high emetic risk: Prevention of chemotherapy-induced nausea and vomiting due to High Emetic Risk parenteral anticancer agents

Coverage by emetogenic risk / Breakthrough management

Guideline-based coverage aligned to emetogenic risk:

High emetic risk prophylaxis: Cover when regimen is high emetic risk as defined by NCCN/ASCO; recommended prophylaxis is a four-drug combination (NK1 receptor antagonist + 5-HT3 receptor antagonist + dexamethasone + olanzapine) with dexamethasone and olanzapine continued on days 2-4 per ASCO; NCCN also recommends 5-HT3 antagonists for high-risk oral agents.

Includes AC regimens, carboplatin AUC ≥4, cisplatin, others listed in policy

Moderate emetic risk prophylaxis: Cover when regimen is moderate emetic risk; for carboplatin AUC ≥4 recommend 3-drug combo (NK1 + 5-HT3 + dexamethasone); other moderate-risk agents: 2-drug combo (5-HT3 + dexamethasone) per ASCO/NCCN.

See list of agents/doses categorized as moderate risk

Low/minimal emetic risk prophylaxis: For low risk cover single agent prophylaxis (5-HT3 or dexamethasone) or as-needed treatment; for minimal risk no routine prophylaxis is recommended per ASCO/NCCN.

NCCN notes as-needed oral options for low/minimal risk

This policy includes oral antiemetic products when they are administered prior to the chemotherapy infusion. The application of preferred-product criteria to oral agents is limited to doses given in the infusion setting and does not apply when oral antiemetics are self-administered by the patient outside of the infusion.

FDA approvals for antiemetic agents are provided for informational context only; FDA approval alone is not a basis for coverage determinations. For oral Aprepitant (Emend capsules), Medicare coverage may be available when the criteria in NCD 110.18 are met and applicable LCDs/LCAs should be consulted. Several injectable antiemetics in this policy do not have a Medicare NCD, LCD, or LCA; in those cases the Medicare Benefit Policy Manual and local Medicare guidance should be referenced and Medicare Advantage plans may develop evidence-based local coverage determinations as allowed by CMS.

Approval of any antiemetic product under this policy is contingent upon meeting the Diagnosis‑Specific Medical Necessity Criteria described in the Coverage Criteria section. If the required diagnosis‑specific criteria are not met, the request for the antiemetic will not be approved under this policy.

Per ASCO guidance, no routine antiemetic prophylaxis is recommended for agents with minimal emetic risk. Requests for routine prophylaxis for minimal‑risk antineoplastic agents will not be supported absent a guideline‑based justification.

Chemotherapy Regimens and Emetogenicity

High emetic risk regimen (examples)
AC combination (any regimen containing an anthracycline plus cyclophosphamide)
Carboplatin AUC ≥ 4
Cisplatin
Cyclophosphamide > 1500 mg/m2
Carmustine > 250 mg/m2
Dacarbazine
Doxorubicin ≥ 60 mg/m2
Epirubicin > 90 mg/m2
Fam-trastuzumab deruxtecan-nxki
Ifosfamide ≥ 2 g/m2 per dose
Mechlorethamine
Melphalan ≥ 140 mg/m2
Streptozocin
Sacituzumab govitecan-hziy

Moderate emetic risk regimen (examples)	Recommended prophylaxis notes
Carboplatin AUC < 4
Per NCCN: 5-HT3 receptor antagonist ± NK1 receptor antagonist; preference for palonosetron IV or granisetron extended‑release injection when an NK1 antagonist is not used; consider adding an NK1 RA if patient has emetic risk factors (younger age <55, female sex, prior CINV, low alcohol use, history of motion/morning sickness, high anxiety).
Cyclophosphamide ≤ 1500 mg/m2
Per NCCN: 5-HT3 receptor antagonist ± NK1 receptor antagonist; preference for palonosetron IV or granisetron extended‑release injection when an NK1 antagonist is not used; consider NK1 RA with risk factors.
Cytarabine > 200 mg/m2
Per NCCN: 5-HT3 receptor antagonist ± NK1 receptor antagonist; preference for palonosetron IV or granisetron extended‑release injection when an NK1 antagonist is not used; consider NK1 RA with risk factors.
Bendamustine
Per NCCN: 5-HT3 receptor antagonist ± NK1 receptor antagonist; preference for palonosetron IV or granisetron extended‑release injection when an NK1 antagonist is not used; consider NK1 RA with risk factors.

Agent/regimen	Emetogenicity category
AC combination (any regimen containing an anthracycline plus cyclophosphamide)
High (>90% frequency of emesis)
Carboplatin AUC ≥ 4
High (>90% frequency of emesis)
Carboplatin AUC < 4
Moderate (30%–90% frequency of emesis)
Cisplatin
High (>90% frequency of emesis)
Cyclophosphamide > 1500 mg/m2
High (>90% frequency of emesis)
Cyclophosphamide ≤ 1500 mg/m2
Moderate (30%–90% frequency of emesis)
Carmustine > 250 mg/m2
High (>90% frequency of emesis)
Carmustine ≤ 250 mg/m2
Moderate (30%–90% frequency of emesis)
Cytarabine > 200 mg/m2
Moderate (30%–90% frequency of emesis)
Doxorubicin ≥ 60 mg/m2
High (>90% frequency of emesis)
Doxorubicin < 60 mg/m2
Moderate (30%–90% frequency of emesis)

first-line

Use with initial and repeat courses: FDA-labeled indications frequently specify prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of chemotherapy; coverage aligned to those indications and guideline recommendations.

Some agents not studied in specific regimens (e.g., Akynzeo injection not studied for AC regimens)

Billing and Diagnosis Codes

Covered J-codes (part 1)HCPCS

J0185	Injection, aprepitant, 1 mg.
J1434	Injection, fosaprepitant (Focinvez), 1 mg.
J1453	Injection, fosaprepitant, 1 mg.
J1454	Injection, fosnetupitant 235 mg and palonosetron 0.25 mg

Covered J/Q-codes (part 2)HCPCS

J1456	Injection, fosaprepitant (teva).
J1626	Injection, granisetron hydrochloride, 100 mcg.
J1627	Injection, granisetron, extended-release, 0.1 mg.
J2405	Injection, ondansetron hydrochloride, per 1 mg.
J2468	Injection, palonosetron hydrochloride (posfrea), 25 mcg.
J2469	Injection, palonosetron HCl, 25 mcg.
J8501	Aprepitant, oral, 5 mg.
J8655	Netupitant 300 mg and palonosetron 0.5 mg, oral.
J8670	Rolapitant, oral, 1 mg.
Q0162	Ondansetron 1 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen.

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Diagnosis codesICD-10

R11.0	Nausea.
R11.10	Vomiting, unspecified.
R11.16	Cannabis hyperemesis syndrome.
R11.2	Nausea with vomiting, unspecified.
T45.1X5A	Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter.
T45.1X5D	Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter.
T45.1X5S	Adverse effect of antineoplastic and immunosuppressive drugs, sequela.
Z51.11	Encounter for antineoplastic chemotherapy

Applicable ICD-10 diagnosis codes (updated)ICD-10

R11.16

Added to list of applicable ICD-10 diagnosis codes

inv-11: Carboplatin AUC — value shown as >= 4

Carboplatin AUC>= 4

Source contextListed by NCCN as a high emetic risk criterion (Carboplatin AUC ≥ 4)

Clinical implicationUse high-emetic-risk prophylaxis (per ASCO/NCCN) when AUC ≥ 4

inv-12: Carboplatin AUC threshold — AUC ≥ 4 (high) vs < 4 (moderate)

Threshold categorizationAUC ≥ 4 = High emetic risk; AUC < 4 = Moderate emetic risk

NCCN listingNCCN lists carboplatin AUC ≥ 4 under high emetic risk and carboplatin AUC < 4 under moderate emetic risk

Prior Authorization, Step Therapy, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-preferred NK1 RA, 5HT3 RA, or NK1 RA/5HT3 RA combination products. Documentation must include either: (1) a history of trial at adequate dose and duration of a preferred NK1 RA or 5HT3 RA with minimal clinical response and a physician statement that the non-preferred product is expected to provide superior clinical response; or (2) documentation of intolerance, contraindication, or adverse event to a preferred NK1 RA or 5HT3 RA and a physician statement that the same issue would not be expected with the non-preferred product. For Medicare members, follow applicable CMS NCD/LCD guidance (for example, NCD 110.18 for oral aprepitant) and any relevant local coverage articles. When member-specific benefit plan language is silent, this policy's rules apply.

Prior authorization required for non-preferred products — include trial and inadequate response to preferred agents or intolerance/contraindication documentation.
Step therapy — trial of a preferred NK1 RA or 5HT3 RA required unless contraindicated or intolerant; document minimal clinical response.
Escalation for breakthrough CINV — follow guideline-based escalation (e.g., ASCO/NCCN) and document changes for subsequent cycles.
Medicare-specific: oral aprepitant (Emend) coverage requires NCD 110.18 criteria; check applicable LCDs/LCAs for oral antiemetics.
Any U.S. FDA–approved product that would fall into UnitedHealthcare Preferred or Nonpreferred categories but is not named in this policy will be considered non-preferred until reviewed by UnitedHealthcare P&T committee.

Key Definitions and Emetogenic Risk

inv-23: Acute Emesis definition — timing and clinical note

DefinitionAcute Emesis: Nausea and/or vomiting that occurs within a few minutes to several hours after administration of certain anticancer agents, commonly resolving within 24 hours.

TimingOccurs minutes to several hours after anticancer agent administration; typically resolves within 24 hours.

Clinical noteRefers to emesis associated with the immediate (acute) phase following chemotherapy administration.

inv-24: Delayed Emesis definition — >24 hours after administration

DefinitionDelayed Emesis: Nausea and/or vomiting that occurs more than 24 hours after anticancer agents.

TimingOnset occurs >24 hours following administration of anticancer therapy.

Background and Clinical Context

Nausea and vomiting related to chemotherapy or radiation can substantially reduce a patient’s quality of life and may lead to poor adherence to anticancer therapy. Effective prophylaxis and prompt management of chemotherapy‑induced nausea and vomiting (CINV) help maintain treatment intensity and reduce the risk of treatment delays or discontinuation.

Line of Therapy Recommendations

first-line

Some agents not studied in specific regimens (e.g., Akynzeo injection not studied for AC regimens)

Policy Revision History

2025-10-01codes_updatedLatest

Applicable ICD-10 diagnosis codes list updated to add R11.16 (cannabis hyperemesis syndrome).

2025-10-01policy_revision

Policy document versioned/posted as 2025D0093K with updates to applicable codes and minor clarifications to coverage criteria wording; supersedes prior archived version 2025D0093J.

(undated CMS reference)medicare_guidance_note

OpenPayer

Antiemetic therapy (NK1 RA and 5HT3 RA) for chemotherapy-induced nausea and vomiting