Archived Policies - Prescription Drugs
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Medical policies are a set of written guidelines that support current standards of practice. They are based on current peer-reviewed scientific literature. A requested therapy must be proven effective for the relevant diagnosis or procedure. For drug therapy, the proposed dose, frequency and duration of therapy must be consistent with recommendations in at least one authoritative source. This medical policy is supported by FDA-approved labeling and nationally recognized authoritative references. These references include, but are not limited to: MCG care guidelines, Hayes, DrugDex (IIb level of evidence or higher), NCCN Guidelines (IIb level of evidence or higher), NCCN Compendia (IIb level of evidence or higher), professional society guidelines, and CMS coverage policy.
Adult T-Cell Leukemia/Lymphoma
Belinostat (Beleodaq®) may be considered medically necessary for nonresponders to first-line therapy.
Mycosis Fungoides (MF)/Sezary Syndrome (SS)
Belinostat (Beleodaq®) may be considered medically necessary in the treatment of patients with Mycosis Fungoides (MF)/Sezary Syndrome (SS) as a single-agent therapy for tumors with aggressive growth rate for:
• Stage IB-IIA MF with histologic evidence of folliculotropic or large cell transformation or stage IIB with generalized extent tumor, transformed, and/or folliculotropic disease with or without skin-directed therapy,
• Stage IV non-Sezary or visceral disease.
Peripheral T-Cell Lymphoma
Belinostat (Beleodaq®) may be considered medically necessary in the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL).
Belinostat (Beleodaq®) may be considered medically necessary as second-line or subsequent therapy for patients with relapsed or refractory angioimmunoblastic T-cell lymphoma, peripheral T-cell lymphoma not otherwise specified, anaplastic large cell lymphoma, or enteropathy-associated T-cell lymphoma.
Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders
Belinostat (Beleodaq®) may be considered medically necessary as a single-agent therapy for patients with relapsed or refractory
• Primary cutaneous anaplastic large cell lymphoma (ALCL) with multifocal lesions,
• Cutaneous ALCL with regional nodes (excludes systemic ALCL)
Belinostat (Beleodaq®) is considered experimental, investigational and/or unproven when not meeting the above noted criteria.
NOTE: The safety and effectiveness of Beleodaq in pediatric patients has not been established. (3)
Non-Hodgkin’s Lymphomas (NHL) are a group of diverse lymphoproliferative disorders originating in, T-lymphocytes, B-lymphocytes or natural killer (NK) cells. Lymphomas are classified based on the cell of origin (B, T, or NK); further classification subdivides lymphomas into those resulting from precursor lymphocytes and those resulting from mature lymphocytes. Other considerations are based on genetic, clinical features, and immunophenotype.
The Revised European American Classification of Lymphoma (REAL) World Health Organization (WHO) classification uses both morphology and immunophenotyping to help determine a pathologic diagnosis.
The National Comprehensive Cancer Network® (NCCN) notes common NHL subtypes of Mature T-cell and NK-cell lymphomas include (6):
• Peripheral T-cell lymphomas (PTCL),
• Mycosis fungoides (MF) and Sezary Syndrome (SS),
• Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders,
• T-cell Large Granular Lymphocytic Leukemia,
• Adult T-cell Leukemia/Lymphoma (ATLL),
• T-cell prolymphocytic leukemia (T-PLL), and
• Extranodal NK/T-cell lymphomas, nasal type (ENKL).
Adult T-cell Leukemia/Lymphoma
NCCN notes the “Adult T-cell Leukemia/Lymphoma (ATLL) is a type of peripheral T-Cell malignancy caused by retrovirus, the human T-cell lymphotropic virus type 1 (HLV-1).” (6)
Mycosis Fungoides and Sezary Syndrome
Mycosis Fungoides is the most common type of cutaneous T-cell Lymphomas (CTCLs). NCCN notes that “MF is an extranodal NHL of mature T-cells with primary cutaneous involvement.” (6)
Sezary syndrome accounts for 1-3% of CTCL cases. NCCN notes that “SS is an erythrodermic, leukemic variant of CTCL and is characterized by significant blood involvement and lymphadenopathy.” (6)
Peripheral T-Cell Lymphomas
Peripheral T-Cell Lymphoma account for approximately 10-15% of all NHL cases in the United States. (1) NCCN notes PTCLs as a “heterogeneous group of lymphoproliferative disorder arising from mature T-cells of post-thymic origin.” (6) Subtypes include:
• Peripheral T-cell lymphomas not otherwise specified (PTCL-NOS),
• Angioimmunoblastic T-cell lymphoma,
• ALK-positive anaplastic large cell lymphoma (ALCL),
• ALK-negative ALCL, and
• Enteropathy-associated T-cell lymphoma
Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders
NCCN reports that “Primary cutaneous CD30+ T-cell lymphoproliferative disorders (LPDs) represent a spectrum that includes primary cutaneous anaplastic large cell lymphoma (ALCL), lymphomatoid papulosis, and “borderline” cases with overlapping clinical and histopathologic features.” (6) Furthermore, NCCN notes that clinical correlation with histopathologic features is essential for establishing the diagnosis of primary cutaneous CD30+ T-cell LPDs’ they note that the diagnosis cannot be made based on pathology review alone. Primary cutaneous anaplastic large cell lymphoma (PC-ALCL) accounts for about 8% of cutaneous lymphoma cases.
Beleodaq is a histone deacetylase (HDAC) inhibitor. The enzyme HDAC, is responsible for the deacetylation of histone proteins that in turn promotes closed chromatin and inhibits gene transcription. By blocking HDAC enzyme, belinostat has a wide range of effects on malignant cells, including, cell cycle growth arrest, inhibition of angiogenesis, inhibition of cell differentiation, apoptosis, autophagy, and immune modulation. (2)
Recently Beleodaq® received accelerated approval from the FDA for treatment of patients with relapsed or refractory peripheral T-cell lymphoma. The indication was approved based on tumor response rate and duration of response. Improvement has not been established for survival or disease-related symptoms. (3) This drug product for this indication has an orphan drug designation. The safety and effectiveness of Beleodaq in pediatric patients have not been established.
Beleodaq® U. S. Food and Drug Administration (FDA)- approval was based on a non-randomized, single-arm international trial performed at 62 centers. One hundred twenty-nine patients with refractory or relapsed Peripheral T-cell Lymphoma (PTCL) were treated with Beleodaq. Treatment consisted of once daily intravenous infusion on Days 1-5 of a 21-day cycle. Cycles were repeated every three weeks until disease progression or unacceptable toxicity. Primary efficacy endpoint was complete and partial response rate. Duration of response was the secondary efficacy endpoint. Response assessments were conducted up to 2 years from the start of the study treatment. Duration response was evaluated from the first day of recorded response to disease progression or death. The overall response rate per was 25.8% (n=31). Median duration of response was 8.4 months (95% confidence interval (CI):4.5 – 29.4). (3) The median time to response was 5.6 weeks (range 4.3 – 50.4 weeks). The median overall survival (OS) was 7.9 months (95% CI:6.1–13.9). The one-year OS (probability of being alive at one year) was 40.9%. (4)
The National Comprehensive Cancer Network (NCCN)
The NCCN Guidelines for Non-Hodkin’s Lymphoma (3.2014 version) indicated an update from the 2.2014 version to include: Belinostat (category 2B) Second-line therapy: for both candidate and non-candidate for transplant for Peripheral T-cell lymphoma patients. (5)
Ongoing Clinical Trials
Multiple trials of belinostat are currently underway for various cancers. There are currently 34 studies listed using the term “belinostat” at ClinicalTrials.gov website.
NCCN Guidelines and Compendium (7) was reviewed through September 19, 2016. The following 2A recommendations for Belinostat/Beleodaq® in the NCCN Compendium are noted below for:
• Non-Hodgkin Lymphoma (NHL) – Adult T-cell leukemia/lymphoma therapy for nonresponders to first-line therapy for acute disease or lymphoma.
• NHL – Mycosis fungoides (MF) / Sezary Syndrome (SS) – Single-agent therapy for tumors with aggressive growth rate for:
o Stage IB-IIA MF with histologic evidence of folliculotropic or large cell transformation or stage IIB with generalized extent tumor, transformed, and/or folliculotropic disease with or without skin-directed therapy,
o Stage IV non-Sezary or visceral disease
• NHL – Peripheral T-cell Lymphoma preferred second-line or subsequent therapy for relapsed or refractory angioimmunoblastic T-cell lymphoma peripheral T-cell lymphoma not otherwise specified anaplastic large cell lymphoma, or enteropathy-associated T-cell lymphoma
• NHL – Primary Cutaneous CD30+T-cell Lymphoproliferative Disorders as single-agent therapy for relapsed or refractory
o Primary cutaneous anaplastic large cell lymphoma (ALCL) with multifocal lesions
o Cutaneous ALCL with regional nodes (excludes systemic ALCL)
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Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
J9032, [Deleted 1/2016: C9442]
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM manual
ICD-9 Procedure Codes
Refer to the ICD-9-CM manual
ICD-10 Diagnosis Codes
Refer to the ICD-10-CM manual
ICD-10 Procedure Codes
Refer to the ICD-10-CM manual
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Peripheral T-Cell Lymphoma (PTCL). Lymphoma Research Foundation. Available at: <www.lymphoma.org> Accessed on 2014 November 21.
2. Belinostat (Beleodaq) TEC Specialty Pharmacy Report #12-2014. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (2014 Aug):1-23.
3. Beleodaq® Highlights of Prescribing Information. United States Food and Drug administration. Available at: < http://www.accessdata.fda.gov> Accessed 2016 September.
4. Beleodaq Summary Review. United States Food and Drug Administration. Available at: <www.accessdata.fda.gov> Accessed 2014 December.
5. NCCN – Non-Hodgkin’s Lymphomas 5.2014 (2014 November 21). National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines™). Available at: <http://www.nccn.org> (accessed on 2014 November 21).
6. NCCN – Non-Hodgkin’s Lymphomas Version 3.2016 (2016 May 3). National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines ™). Available at: <http://www.nccn.org> (accessed on 2016 November).
7. NCCN –Belinostat (2016). National Comprehensive Cancer Network Drugs & Biologics Compendium. Available at <http://www.nccn.org> (accessed on 2016 September).
|4/15/2017||Document updated with literature review. The following conditional coverage was added for: Adult T-Cell Leukemia/Lymphoma, Mycosis Fungoides (MF)/ Sezary Syndrome (SS), Peripheral T-cell lymphoma and Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders. The following statement was changed from: Belinostat (Beleodaq®) is considered experimental, investigational and/or unproven when used in the treatment of any other conditions to: Belinostat (Beleodaq®) is considered experimental, investigational and/or unproven when not meeting the above noted criteria.|
|1/1/2015||New medical document. Belinostat (Beleodaq®) may be considered medically necessary in the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL). Belinostat (Beleodaq®) is considered experimental, investigational and/or unproven when used in the treatment of any other conditions.|