Avastin (bevacizumab) — Medical Benefit Drug Coverage (VNSNY CHOICE SelectHealth Plan)
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This policy covers medical benefit (provider-administered) use of Avastin (bevacizumab) under the VNSNY CHOICE SelectHealth Plan, describing covered indications, billing codes, and clinical background relevant to prior authorization and administration.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered Indications (FDA-approved)
Covered when FDA-indicated uses apply.
Policy lists specific combination regimens and limitations (e.g., not indicated for adjuvant treatment of colon cancer).
Avastin (bevacizumab) is not indicated for adjuvant treatment of colon cancer. This is a stated Limitation of Use specific to treatment of colorectal cancer and applies when Avastin would otherwise be considered for post‑surgical (adjuvant) therapy rather than for the FDA‑approved metastatic or recurrent settings listed in the policy.
Initial Therapy
Initial Therapy — FDA-approved combination regimens
Initiation is covered when ALL of the following are met.
Policy enumerates specific chemotherapy combinations and settings (e.g., first- or second-line metastatic colorectal cancer with fluorouracil-based chemotherapy; second-line colorectal combinations after progression on an Avastin-containing regimen; non-squamous NSCLC with carboplatin + paclitaxel for first-line; ovarian cancer combinations and sequences).
Step Therapy / Specific Use Restrictions
| Step | Clinical scenario | Required prior therapy | Coverage stance |
|---|---|---|---|
| 1 | Second-line treatment of metastatic colorectal cancer in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for patients who have progressed on a first-line Avastin-containing regimen. | Progression on a first-line Avastin-containing regimen (first-line Avastin + fluorouracil-based chemotherapy). | Covered with criteria |
Coding and Procedure Codes
Provider Actions & Billing
Medical benefit prior authorization — follow buy‑and‑bill prior auth process
Avastin (bevacizumab) is covered as a provider‑administered medication under the member's medical benefit via the buy‑and‑bill process; when prior authorization is required, follow the plan's prior authorization process for provider‑administered drugs (referencing HCPCS J9035 for bevacizumab).
- Reference HCPCS J9035 (Injection, bevacizumab, 10 mg) when submitting prior authorization requests.
Alert — buy‑and‑bill pathway and code inclusion are not guarantees of payment
Coverage is available only under the medical benefit buy‑and‑bill pathway; inclusion of procedure codes in the policy is for reference and does not ensure coverage or payment. Providers should verify benefit and reimbursement prior to administration.
- The list of procedure codes is provided for reference only and may not be all inclusive.
- Inclusion of a code does not imply any right to reimbursement or guarantee claim payment.
Billing and documentation — bill under medical benefit with J9035 and appropriate administration codes
Bill bevacizumab under the medical benefit using the appropriate HCPCS/CPT procedure codes (e.g., HCPCS J9035 for bevacizumab) and include applicable chemotherapy or intravitreal administration CPT codes as appropriate. Ensure documentation supports the dose, regimen, and combination therapy per the FDA‑indicated setting.
Coverage pathway and reimbursement caveat — code inclusion does not assure payment
Inclusion of a procedure code in the policy's Applicable Codes table is for reference only; it does not guarantee reimbursement or claim payment — coverage is achieved via the medical benefit buy‑and‑bill process and is subject to benefit verification and claims adjudication.
- Coverage is available under the member's medical benefit via buy‑and‑bill for provider‑administered drugs.
- The policy explicitly states the inclusion of a code does not imply a right to reimbursement or guarantee claim payment.
Site of Care
Infusion center — provider‑administered buy‑and‑bill billing
Avastin is covered when administered in an infusion center as a provider‑administered medication billed under the medical benefit via buy‑and‑bill; follow the plan's authorization and billing procedures for such settings.
- Administer and bill Avastin using buy‑and‑bill processes for infusion center providers.
Clinical Background
Bevacizumab is a recombinant humanized monoclonal IgG1 antibody that binds vascular endothelial growth factor (VEGF) to inhibit VEGF–receptor interaction and angiogenesis. It is used across multiple solid tumor indications, most often in combination with cytotoxic chemotherapy regimens specified in the label, including colorectal cancer, non‑small cell lung cancer, recurrent glioblastoma, metastatic renal cell carcinoma, cervical cancer, and certain epithelial ovarian/fallopian tube/primary peritoneal cancers.
As a monoclonal anti‑VEGF agent, bevacizumab’s clinical role is as an adjunct to systemic chemotherapy in metastatic or recurrent disease settings rather than as monotherapy in the adjuvant colon cancer setting; the policy explicitly notes this distinction by listing adjuvant colon cancer as a limitation of use.
Definitions
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