Recarbrio (imipenem-cilastatin-relebactam)

POLICY NUMBER

L.5.01.548

Recarbrio (imipenem-cilastatin-relebactam)

DESCRIPTION

Recarbrio (imipenem-cilastatin-relebactam) is indicated in patients 18 years of age and older with hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia and in patients 18 years of age and older who have limited or no alternative treatment options, for the treatment of complicated urinary tract infections (cUTI), including pyelonephritis and complicated intra-abdominal infections (cIAI) caused by susceptible gram-negative microorganisms.

POLICY

Recarbrio (imipenem-cilastatin-relebactam) is considered not medically necessary as there are other alternatives covered by the Plan for treatment of hospital-acquired bacterial pneumonia, ventilator-associated bacterial pneumonia, complicated urinary tract infections (cUTI), and complicated intra-abdominal infections (cIAI).

Recarbrio (imipenem-cilastatin-relebactam) is considered investigational for all other conditions not outlined in this policy.

POLICY EXCEPTIONS

State Health Plan (State and School Employees) Participants

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; andB. appropriate with regard to standards of good medical practice; andC. not solely for the convenience of the Member, his or her Provider; andD. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

04/13/2020: New policy added.

06/26/2020: Code Reference section updated to add new HCPCS code J0742, effective 07/01/2020.

02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.

07/01/2023: Policy Exceptions updated regarding State Health Plan (State and School Employees) Participants.

03/20/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding indications for Recarbrio (imipenem-cilastatin-relebactam). Policy statement revised to add that Recarbrio (imipenem-cilastatin-relebactam) is not medically necessary for the treatment of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders." Sources updated.

SOURCE(S)

Recarbrio prescribing information. Merck Sharp & Dohme LLC. October 2024. Last accessed February 2025.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Not Medically Necessary Codes

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