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DESCRIPTIONRadioimmunotherapy involves the administration of an antibody linked to a radioisotope, targeted to a specific cell type. Ibritumomab (Zevalin®) and tositumomab (Bexxar®) are radioimmunoconjugates that target cell surface CD20 found on normal B lymphocytes and more than 90% of B-cell non-Hodgkin lymphomas (NHL). CD20-based radioimmunotherapy for NHL is similar to the anti-CD20 monoclonal antibody rituximab, which is widely used against B-cell malignancies, however, 90Y-ibritumomab tiuxetan uses a monoclonal anti-CD20 antibody to deliver beta-emitting yttium-90 and 131I-tositumomab is an iodine-131-loaded antibody.
Radioimmunotherapy offers several advantages over external-beam irradiation in the treatment of NHL, a relatively radiosensitive disease. Radioimmunotherapy is given intravenously and, therefore, normal tissues overlying the tumor are spared significant radiation exposure. Radioimmunotherapy provides systemic radiation treatment to known as well as unsuspected tumor cells and a ”bystander effect” may be observed, since the radiation emitted from the isotopes is deposited over several cell diameters with poorly perfused or non-antigen-expressing cells within a tumor mass suffering the cytotoxic radiation effect.
B-cell and other NHLs can be subdivided into major subcategories as indolent and aggressive. Indolent B-cell lymphomas (e.g., follicular lymphoma, a common subtype) usually present with advanced stage disease and are not considered curable with current treatments, including chemotherapy. The disease course is usually prolonged, with a median survival of 7–10 years, and is characterized by initial response to chemotherapy, multiple relapses and increasing resistance to treatment. In addition, approximately 60% of patients may transform to a more aggressive type of lymphoma. Although rituximab is widely used in the treatment of B-cell NHL, not all patients respond, and a certain number of patients eventually develop resistance to the drug, necessitating additional treatments after rituximab.
Ibritumomab tiuxetan (Zevalin®) was granted accelerated approval by the U.S. Food and Drug Administration (FDA) in February 2002 for the treatment of patients with relapsed or refractory low-grade, follicular or transformed B-cell non-Hodgkin lymphoma, including patients with rituximab refractory follicular non-Hodgkin lymphoma.
Tositumomab (Bexxar®) was granted approval by the FDA in June 2003 for the treatment of patients with CD20-positive, follicular, non-Hodgkin lymphoma, with or without transformation, whose disease is refractory to rituximab and has relapsed following chemotherapy.
POLICYA single course of tositumomab (Bexxar®) used for the treatment of antigen CD20-positive, follicular, non-Hodgkin lymphoma, with or without transformation, whose disease is refractory to rituximab and has relapsed following chemotherapy may be considered medically necessary.
A single course of ibritumomab tiuxetan (Zevalin®) used for the treatment of patients with relapsed or refractory CD-20-positive low-grade, follicular, or transformed B-cell non-Hodgkin lymphoma, including patients with rituximab refractory follicular non-Hodgkin lymphoma, may be considered medically necessary.
The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®)* for consolidation after chemotherapy in non-Hodgkin lymphoma patients who achieve a partial or complete response may be considered medically necessary.
The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) for the initial treatment of follicular lymphoma may be considered medically necessary in patients who are unable to tolerate standard chemotherapy, e.g., elderly or frail patients.
Radioimmunotherapy with tositumomab or ibritumomab tiuxetan for consolidation of a first remission following chemotherapy for de novo aggressive B-cell NHL is considered investigational.
The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) as part of a preparatory regimen prior to hematopoietic stem-cell transplantation is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY6/2/2009: Policy added
7/16/2009: Approved by Medical Policy Advisory Committee (MPAC)
12/30/2010: Policy statement regarding the use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) for the initial treatment of follicular lymphoma changed to may be considered medically necessary under specific conditions. Policy statement regarding the use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) for consolidation after chemotherapy in patients who achieve a partial or complete response also changed to may be considered medically necessary.
09/28/2011: Policy reviewed; no changes.
04/10/2013: Policy description updated. Added the following policy statement: Radioimmunotherapy with tositumomab or ibritumomab tiuxetan for consolidation of a first remission following chemotherapy for de novo aggressive B-cell NHL is considered investigational.
SOURCESBlue Cross & Blue Shield Association policy # 8.01.50
CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.
The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.