CurrentViva Health PlanPolicy IC-0367

Elitek (rasburicase) Coverage Criteria

Customize your policy alerts

Sign up for vivahealthplan Policy IC-0367 alerts

Get alerted when Policy IC-0367 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs prior authorization, medical necessity, dosing, and billing requirements for intravenous Elitek (rasburicase) used to prevent or treat hyperuricemia associated with tumor lysis in Viva Health Plan members receiving chemotherapy for leukemia, lymphoma, or solid tumors.

Policy Summary

PayerViva Health Plan

PolicyElitek (rasburicase) Coverage Criteria

Policy CodePolicy IC-0367

Change TypeNo material change

Effective DateN/A

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for a single 5-day course when all clinical criteria for hyperuricemia due to tumor lysis are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 daysMaximum therapy duration

45Maximum daily HCPCS units

1Maximum treatment courses

E88.3Covered diagnosis

J2783

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentViva Health PlanPolicy IC-0367

Elitek (rasburicase) Coverage Criteria

Customize your policy alerts

Sign up for vivahealthplan Policy IC-0367 alerts

Get alerted when Policy IC-0367 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerViva Health Plan

PolicyElitek (rasburicase) Coverage Criteria

Policy CodePolicy IC-0367

Change TypeNo material change

Effective DateN/A

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for a single 5-day course when all clinical criteria for hyperuricemia due to tumor lysis are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 daysMaximum therapy duration

45Maximum daily HCPCS units

1Maximum treatment courses

E88.3Covered diagnosis

J2783

Coverage Criteria

Initial Therapy

Coverage is provided when ALL of the following criteria are met:

ALL of the following

Member is at least 1 month of age.
Member does NOT have any FDA-labeled contraindications to rasburicase, including glucose-6-phosphate dehydrogenase (G6PD) deficiency or a history of reactions to rasburicase such as anaphylaxis, severe hypersensitivity, hemolysis, or methemoglobinemia.
Member is receiving chemotherapy for leukemia, lymphoma, or solid tumors.
ONE of the following
- Prophylaxis
  - Rasburicase is being used as prophylactic therapy when chemotherapy is expected to result in tumor lysis and subsequent elevation of plasma uric acid.
  - ANY of the following
    High-risk tumor type, including Burkitt lymphoma/leukemia, lymphoblastic lymphomas, acute lymphoblastic leukemia (ALL), diffuse large B-cell lymphoma (DLBCL), or another tumor type with a high proliferative rate or high sensitivity to cytotoxic therapy; or treatment with high-risk medications such as venetoclax, chemoimmunotherapy, lenalidomide, or obinutuzumab.
    Progressive disease after small-molecule inhibitor therapy.
    Bulky disease or large tumor burden, including any lymph node ≥10 cm, elevated LDH ≥2 times the upper limit of normal, absolute lymphocyte count ≥25,000/mcL, white blood cell count >50,000/mcL, organ infiltration, or bone marrow involvement.
    Spontaneous tumor lysis syndrome.
    Dehydration, volume depletion, or a situation in which adequate hydration may be difficult or impossible.
- Treatment
  - Rasburicase is being used to treat hyperuricemia that developed despite standard prophylactic therapies, such as hydration, allopurinol, or febuxostat.

Rasburicase is contraindicated in members with glucose-6-phosphate dehydrogenase (G6PD) deficiency and in members with a history of reactions to rasburicase, including anaphylaxis, severe hypersensitivity, hemolysis, or methemoglobinemia.

Initial prior authorization is valid for a single course of treatment consisting of up to 5 days of therapy. Renewal is not permitted. Dosing beyond 5 days or administration of more than one course is not recommended; Elitek is indicated only for a single course of treatment.

Billing and Coding

HCPCS CodeHCPCSCovered

J2783

Injection, rasburicase, 0.5 mg; 1 billable unit = 0.5 mg

NDC(s)NDCCovered

00024-5150-xx	Elitek 1.5 mg single-dose vial
00024-5151-xx	Elitek 7.5 mg single-dose vial

Covered Diagnosis CodesICD-10Covered

E88.3

Tumor lysis syndrome

Daily HCPCS unit limit

Daily limit45 billable HCPCS units per day

Duration5 days

Course limitOne 5-day therapy course only

Bulky disease

ConditionBulky disease or large tumor burden

Lymph-node thresholdAny lymph node ≥10 cm

Measurement

Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Elitek. Initial authorization is limited to one treatment course consisting of up to 5 days of therapy for eligible members with hyperuricemia due to tumor lysis.

Member is receiving chemotherapy for leukemia, lymphoma, or solid tumors.
Use is for prophylaxis when chemotherapy is expected to cause tumor lysis and elevated plasma uric acid in a member at high risk for hyperuricemia, or for treatment of hyperuricemia despite standard prophylaxis such as hydration, allopurinol, or febuxostat.

Denial Risk

Clinical Eligibility Required

Coverage is not approved when clinical eligibility requirements are not met, including age or FDA-labeled contraindications to rasburicase.

Member must be at least 1 month of age.

Background

Rasburicase is used to reduce uric acid in patients at risk for or experiencing tumor lysis syndrome during cancer treatment. Coverage may apply for prophylaxis when chemotherapy is expected to cause tumor lysis and elevated plasma uric acid in a member at high risk for hyperuricemia, or for treatment when hyperuricemia develops despite standard prophylaxis such as hydration, allopurinol, or febuxostat.

Definitions and Risk Factors

High risk for hyperuricemia

High-risk tumor or treatmentHigh-risk tumor type or high-risk medication, such as venetoclax, chemoimmunotherapy, lenalidomide, or obinutuzumab

Disease burden or progressionProgressive disease after small-molecule inhibitor therapy, bulky disease or large tumor burden, or spontaneous tumor lysis syndrome

Hydration riskDehydration, volume depletion, or situations where adequate hydration may be difficult or impossible

Renal riskRenal disease or renal involvement by tumor, including pre-existing nephropathy, nephrotoxin exposure, oliguria, or acidic urine

Pre-existing laboratory abnormalitiesPre-existing hyperuricemia or hyperphosphatemia

Initial Therapy Criteria

Hyperuricemia Due to Tumor Lysis — Initial Therapy Criteria

Initial approval is provided for hyperuricemia due to tumor lysis when all applicable criteria are met.

Initial Elitek approval

Qualifying use pathway
- High-risk prophylaxis
  - High-risk factor
    The member has a high-risk tumor type or is receiving a high-risk medication.
    Examples include Burkitt lymphoma or leukemia, lymphoblastic lymphoma, acute lymphoblastic leukemia, diffuse large B-cell lymphoma, other tumors with a high proliferative rate or high sensitivity to cytotoxic therapy, venetoclax, chemoimmunotherapy, lenalidomide, or obinutuzumab.
    The member has progressive disease after small-molecule inhibitor therapy.

Continuation and Renewal

No Renewal

Renewal is not available; authorization cannot extend beyond the initial single course.

No renewal: Prior authorization may not be renewed, and there is no covered continuation or repeat course.Single 5-day course

Initial authorization is limited to one course consisting of 5 days of therapy; authorization cannot extend beyond that course.

Quantity Limits

Elitek (rasburicase)

DrugElitek (rasburicase)

Daily HCPCS limit45 billable HCPCS units daily

Duration and course limit5 days; one 5-day therapy course only

Policy Summary

PayerViva Health Plan

PolicyElitek (rasburicase) Coverage Criteria

Policy CodePolicy IC-0367

Change TypeNo material change

Effective DateN/A

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for a single 5-day course when all clinical criteria for hyperuricemia due to tumor lysis are met.

SourceLink

On This Page

Renal disease or renal involvement by tumor, including pre-existing nephropathy, exposure to nephrotoxins, oliguria, or acidic urine.

Pre-existing hyperuricemia (serum/plasma uric acid >7.5 mg/dL) or hyperphosphatemia (serum/plasma phosphate >4.5 mg/dL).

Elevated LDH

ConditionElevated lactate dehydrogenase (LDH)

ThresholdLDH ≥2 times the upper limit of normal (ULN)

ComparisonUpper limit of normal

Absolute lymphocyte count

TestAbsolute lymphocyte count

Qualifying threshold≥25,000/mcL

UnitCells per microliter (mcL)

White blood cell count

TestWhite blood cell count

Qualifying threshold>50,000/mcL

UnitCells per microliter (mcL)

Pre-existing hyperuricemia

ConditionPre-existing hyperuricemia

Qualifying thresholdSerum or plasma uric acid >7.5 mg/dL

SpecimenSerum or plasma

Pre-existing hyperphosphatemia

ConditionPre-existing hyperphosphatemia

Qualifying thresholdSerum or plasma phosphate >4.5 mg/dL

SpecimenSerum or plasma

Member must not have an FDA-labeled contraindication, including G6PD deficiency or a history of rasburicase-associated anaphylaxis, severe hypersensitivity, hemolysis, or methemoglobinemia.

Denial Risk

Repeat Course or Extended Therapy

Authorization will not be renewed when the authorized duration has been exceeded. Elitek is indicated for a single course only; therapy beyond the initial course or administration beyond 5 days is not recommended and may result in denial or non-renewal.

Prior authorization validity may not be renewed.
Do not administer more than one course of treatment.
Do not extend therapy beyond 5 days; the usual dose is 0.2 mg/kg intravenously daily for up to 5 days.

The member has bulky disease or a large tumor burden.

Examples include any lymph node ≥10 cm, elevated LDH ≥2 times the upper limit of normal, absolute lymphocyte count ≥25,000/mcL, white blood cell count >50,000/mcL, organ infiltration, or bone marrow involvement.

The member has spontaneous tumor lysis syndrome.

The member has dehydration, volume depletion, or a situation in which adequate hydration may be difficult or impossible.

The member has renal disease or renal involvement by tumor.

Examples include pre-existing nephropathy, exposure to nephrotoxins, oliguria, or acidic urine.

The member has pre-existing hyperuricemia or hyperphosphatemia.Serum/plasma uric acid >7.5 mg/dL or phosphate >4.5 mg/dL

Treatment after failed prophylaxis: The member developed hyperuricemia despite standard prophylactic therapies such as hydration, allopurinol, or febuxostat.

No FDA-labeled contraindication: The member does not have G6PD deficiency or a history of rasburicase-associated anaphylaxis, severe hypersensitivity, hemolysis, or methemoglobinemia.