|Policy #:||DRUG.00039||Current Effective Date:||07/15/2014|
|Status:||Revised||Last Review Date:||05/15/2014|
Trastuzumab (Herceptin, Genentech, Inc., San Francisco, CA) is a humanized recombinant DNA monoclonal antibody that targets tumor cells that overexpress the human epidermal growth factor receptor 2 (HER2) protein and/or amplification of the HER2 gene.
Note: Please see the following for additional information:
I. Breast Cancer
Trastuzumab is considered medically necessary for individuals with breast cancer who meet criteria (A) and one or more of the indications listed in (B) below:
II. Gastric, Esophageal and Gastroesophageal Adenocarcinoma
Trastuzumab is considered medically necessary for individuals with advanced gastric, esophageal or gastroesophageal (GE) junction adenocarcinoma who meet criteria: (A) and in addition, both of the criteria listed in (B) below:
Investigational and Not Medically Necessary:
Trastuzumab is considered investigational and not medically necessary for individuals who do not meet the criteria listed above.
Concomitant use of trastuzumab with other targeted biologic agents not otherwise noted in the criteria above (including but not limited to erlotinib, cetuximab, panitumumab, and bevacizumab) is considered investigational and not medically necessary.
Trastuzumab originally received approval in 1998, by the U.S. Food and Drug Administration (FDA) for the treatment of individuals with metastatic breast cancer whose tumors overexpressed HER2 (referred to as HER2+) and who had received one or more chemotherapy regimens for the metastatic disease. Additionally, trastuzumab in combination with paclitaxel as part of a first-line regimen for metastatic disease was also approved. In 2006 and 2008, trastuzumab received additional FDA approval for use in the adjuvant setting in combination therapy for individuals with positive lymph nodes or node-negative disease with high-risk features, or as a single agent following multi-modality anthracycline based therapy. Although there are different FDA approved dosing recommendations, the maximum treatment period for adjuvant therapy is 52 weeks. Treatment for metastatic breast cancer may continue until disease progression (Product Information, 2010).
These indications were based on the results of a variety of randomized controlled trials studying the role of trastuzumab as a treatment of metastatic breast disease, as neoadjuvant therapy or adjuvant therapy. The trials examined the use of trastuzumab as monotherapy or in combination with a variety of other therapies and all reported improved disease free survival.
In 2012, the FDA approved pertuzumab (Perjeta™, Genentech, Inc., San Francisco, CA) in combination with trastuzumab and docetaxel, for individuals with HER2+ metastatic breast cancer who have not previously received anti-HER2 therapy or chemotherapy treatment for the metastatic disease. The approval was based on the significantly improved progression-free survival (PFS) results from the phase 3, double-blind, placebo-controlled Clinical Evaluation of Pertuzumab and Trastuzumab (CLEOPATRA) trial. A total of 808 participants with HER2+ metastatic breast cancer were enrolled into the study. Participants were eligible if they did not receive prior chemotherapy for the metastatic disease. One hormonal treatment prior to randomization was allowed. The median PFS was 18.5 months for those randomized to the group treated with trastuzumab, pertuzumab and docetaxel compared to a median PFS of 12.4 months in the control group treated with placebo plus trastuzumab and docetaxel. The control group had more frequent left ventricular systolic dysfunction (8.3%) compared to the treatment group combining trastuzumab and pertuzumab (4.4%) (Baselga, 2012).
Gianni and colleagues (2011) reported updated results from the ongoing phase 3, randomized, open-label, multi-center international HERA (Herceptin Adjuvant) trial comparing trastuzumab treatment for 1 year and 2 years with observation after standard neoadjuvant and/or adjuvant therapy in women with early breast cancer. The interim analysis at a median 1-year follow-up demonstrated a significantly improved disease-free survival (DFS) with trastuzumab compared to chemotherapy alone (hazard ratio [HR] 0.54; 95% confidence interval [CI], 0.43–0.67). As a result, the protocol was amended in 2005, to allow individuals from the control group who had not relapsed to cross over and receive trastuzumab. Based on recommendations from the independent data monitoring committee, the 2-year trastuzumab group data are not being released until the final event-driven analysis. Planned data updates occur every two years for the 1-year trastuzumab treatment and the observation group. With a median follow-up of 48.4 months, Gianni presented updated data for the 1-year and observation cohorts. The 4-year disease-free survival rate in the 1-year trastuzumab treatment group was 78.6% compared to 72.2% (HR 0.76; 95% CI, 0.66–0.87; p<0.0001) for the observation group. The 4-year overall survival (OS) rate was not statistically significant with 89.3% for the trastuzumab group and 87.7 % (p=0.11) in the observation group. Of the 1698 participants in the observation group, 885 (52%) of the individuals crossed over and began trastuzumab treatment. In a comparison of the individuals in the selective crossover group, the estimated HR for fewer disease free survival events was significant (p=0.0077) compared to the observation cohort. The authors concluded although the OS benefit was no longer statistically significant, the benefit from 1 year treatment with trastuzumab is maintained with longer follow-up. The data from treatment with 2 years of trastuzumab is still pending.
It should be noted the majority of randomized studies of trastuzumab as adjuvant therapy enrolled individuals with breast cancer and positive axillary nodes, or individuals with negative nodes but with a primary tumor measuring greater than 1 cm in greatest dimension. The size limitation in individuals with negative nodes was based on the assumption that small tumors (less than 1 cm in diameter) were at low risk of recurrence such that trastuzumab would not be beneficial, particularly considering the cardiac side effects. However, in 2008, data presented at the San Antonio Breast Cancer Symposium challenged this assumption. Gonzalez-Angulo and colleagues (2009) performed a retrospective review of 1390 individuals with early breast cancer no larger than 1 cm in any dimension and negative axillary nodes in the Breast Cancer Management Database at the University of Texas M.D. Anderson Cancer Center (MDACC). A total of 965 individuals were eligible for the study. A second set of 350 individuals who met identical clinical criteria at two other institutions in Belgium and Austria were used to validate the MDACC results. Individuals were divided into three groups: triple negative (i.e., negative hormone receptors and negative HER2), HER 2+ (regardless of hormone status) and hormone receptor-positive and HER2 negative. Individuals with HER2+ breast cancer had a significantly worse relapse free survival compared to individuals with hormone-positive cancer or triple-negative breast cancer (p<0.0001). The authors concluded that individuals with even small (less than 1 cm) HER2+ tumors have a significant risk of relapse and that adjuvant systemic therapy with trastuzumab should be considered. Therefore, adjuvant trastuzumab is considered in any individual with HER 2+ early breast cancer regardless of nodal status or size of primary tumor.
Blackwell and colleagues (2010) reported results from a phase 3 randomized study (EGF104900) of lapatinib alone or in combination with trastuzumab for women with HER2-positive, trastuzumab-refractory metastatic breast cancer. A total of 296 participants were enrolled with random assignment equally to each treatment arm. Assessments were completed every 4 weeks through week 16, and then every 8 weeks thereafter. Participants were allowed to cross over to combination therapy if objective disease progression was noted after receiving a minimum of 4 weeks of monotherapy with lapatinib. In 2012, the final planned analysis of OS included 291 participants who were available for efficacy analysis with 145 in the lapatinib monotherapy group and 146 in the combination lapatinib and trastuzumab group. After progression of disease while on lapatinib monotherapy, 77 participants were allowed to cross over and received combination therapy. The primary endpoint of PFS was significantly improved in the individuals who were treated with combination trastuzumab and lapatinib compared to lapatinib monotherapy (HR, 0.71; 95% CI, 0.58 to 0.94; p=0.011). Median PFS was 11.1 weeks with combination therapy compared to 8.1 weeks PFS for monotherapy with lapatinib. The median OS was 14 months for the combination therapy versus 9.5 months for lapatinib monotherapy (HR, 0.74; 95% CI, 0.57 to 0.96; p=0.021). Adverse events had similar incidence rates of 94% in the combination cohort compared to 90% in the single-agent group. A significantly higher rate of diarrhea was noted in participants in the combination arm versus the monotherapy arm (62% vs. 48%). Serious adverse events were reported by 26% in the cohort receiving combination therapy and 16% in the cohort receiving monotherapy. The authors noted the 4.5 month survival improvement with the trastuzumab combination supports the preclinical data that "lapatinib plus trastuzumab combination has synergistic antiproliferative effects" (Blackwell, 2012).
In the GBG26/BIG 3-05 phase 3 RCT, participants were randomized to start single agent capecitabine or continue trastuzumab and start capecitabine at the time of progressive disease while on first-line regimens that included trastuzumab. Baselga and colleagues (2012) reported there was no significant survival difference in the final OS analysis between treatment arms. However, the post-hoc analysis demonstrated a better progression survival than those who did not receive third-line anti-HER2 therapy. Post-progression survival of 18.8 months was noted in participants who continued or restarted anti-HER2 therapy after second progression compared to 13.3 months in those who did not receive third-line anti-HER2 therapy (p=0.02). The authors note that the results need to be confirmed in a larger meta-database analysis to overcome potential bias related to the post-hoc review. The authors concluded the use of anti-HER2 therapy throughout multiple lines continues to be recommended.
The clinical practice guideline (CPG) of the National Comprehensive Cancer Network® (NCCN, 2014) recommends the use of trastuzumab to treat breast cancer. The CPG recommends "continued trastuzumab following progression on first line-trastuzumab containing chemotherapy for metastatic breast cancer. The optimal duration of trastuzumab in patients with long-term control of disease is unknown."
In a retrospective series of 80 individuals with brain metastases from breast cancer, the use of lapatinib and trastuzumab-based therapy significantly improved OS compared to chemotherapy or radiotherapy alone (Bartsch, 2012). Median OS was 13 months for those receiving trastuzumab with or without chemotherapy and at 24 months of follow-up, the median OS for lapatinib (with or without trastuzumab or chemotherapy) was not reached.
A phase 3 randomized trial (GeparQuinto, GBG 44) enrolled individuals with untreated HER2-positive, operable or locally advanced breast cancer randomized to treatment with lapatinib (ECH-TL group) versus trastuzumab (ECH-TH group) in combination with neoadjuvant anthracycline-taxane-based chemotherapy. There were improved rates of pathologic complete response in the ECH-TH group with 93 (30.3%) of 307 participants compared to 70 (22.7%) of 308 participants in the ECL-TL (odds ratio [OR] 0.68 [95% CI, 0.47 - 0.97]; p=0.04) (Untch, 2012).
Baselga and colleagues reported results from NeoALTTO, an open-label, multicenter, phase 3 randomized trial of dual HER2 inhibition with lapatinib and trastuzumab versus lapatinib alone or trastuzumab alone in the neoadjuvant setting. Individuals received 6 weeks of the assigned biologic agent(s) followed by an additional 12 weeks of therapy in combination with paclitaxel prior to definitive breast surgery. A significantly higher (p=0.0001) pathologic complete response (pCR) was noted in the combination lapatinib and trastuzumab group (51.3%; 95% CI, 43.1–59.5) compared to the group treated with trastuzumab alone (29.5%; 22.4–37.5). Grade 3 and 4 adverse events were more frequent in the dual lapatinib and trastuzumab cohort (21.7%) compared to 1.3% in trastuzumab alone and 18.8% in the lapatinib group. Participants who were unable to complete the planned therapy due to side effects were higher in the groups treated with lapatinib alone (18.8%) and combination lapatinib and trastuzumab (39.5%) versus the trastuzumab alone group (8.1%). The authors noted the results support the "proof of concept" and with longer follow-up, DFS and OS will be reported. Additional long-term data and studies are needed to confirm dual inhibition of HER2 in the neoadjuvant setting is safe and effective.
Clinical indications combining trastuzumab with lapatinib are a category 2A offlabel recommendation in the NCCN practice guidelines (2014) for HER2 overexpressing metastatic breast cancer. The CPG also notes the optimal neoadjuvant regimen for HER2-targeting remains uncertain.
Gastric, Esophageal and Gastroesophageal Carcinoma
In October 2010, the FDA approved trastuzumab "in combination with cisplatin and capecitabine or 5-fluorouracil, for the treatment of individuals with HER2 overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma, who have not received prior treatment for metastatic disease." Treatment for gastric cancer may continue until disease progression (Product Information, 2014).
Bang (2010) and colleagues reported results from ToGA (trastuzumab for gastric cancer) a multicenter, phase 3 randomized trial investigating trastuzumab as first-line treatment of locally advanced, recurrent or metastatic gastric and gastroesophageal adenocarcinoma. A total of 3,807 individuals with gastric carcinoma were tested for HER2. Eligibility for inclusion in the study was HER2 positivity defined as IHC 3+ or FISH positive (defined as HER2: CEP17 ratio ≥2.0) (Bang, 2010). Of these, 594 individuals had HER2+ tumors and were randomized to a control group receiving chemotherapy or to a treatment group receiving chemotherapy plus trastuzumab. Chemotherapy consisted of either 5-fluorouracil or capecitabine in conjunction with cisplatin every 3 weeks, for six cycles. The treatment group received 6 cycles of chemotherapy plus trastuzumab on Day 1 of each cycle and trastuzumab was continued every 3 weeks until disease progression. The median number of trastuzumab cycles was 8 (range 1-49). At 18.6 months of follow-up, the median OS was 13.5 months in the trastuzumab arm, compared to 11.1 months OS in the control group (p=0.0048) at a median follow-up of 17.1 months. The overall response rate (ORR) was also significantly improved for the trastuzumab group compared to controls, 47.3% vs. 34.5%, respectively.
The NCCN practice guideline for gastric cancer (2013) and the National Cancer Institute PDQ® (2014) for gastric cancer list the use of trastuzumab as a part of combination therapy for HER2-positive advanced gastric, esophageal and gastroesophageal adenocarcinoma.
In a Cochrane Review of chemotherapy for gastric cancer (Wagner, 2010), the authors recommended HER2 overexpression testing for all gastric cancers and use of trastuzumab in combination therapy with cisplatin and 5FU for HER2-positive gastric carcinomas.
The key selection criterion for trastuzumab is HER2 overexpression. In the pivotal breast cancer clinical trials, HER2 overexpression was determined by scores of 2+ or 3+ resulting from the IHC Clinical Trial Assay (CTA), which is utilized in research settings. Individuals with scores of 0 or 1+ were not included in the trials. Subsequently, the FDA has approved commercially available IHC tests to determine HER2 overexpression, which include Herceptest® (Dako Corp., Glostrup, Denmark) and Pathway® (Ventana Medical Systems, Tucson, AZ). In addition, FDA approved tests which measure fluorescent in situ hybridization (FISH) of the HER2/neu protein including PharmDx™ (Dako Corp., Glostrup Denmark), Dako HER2 FISH PharmDx™ test kit (Dako Corp., Glostrup, Denmark), PathVysion™ (Abott-Vysis Inc, Downers Grove, IL) and INFORM (Ventana Medical Systems, Tucson, AZ).
In 2007, the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) developed joint guideline recommendations for HER2 testing in breast cancer and the guideline was updated in 2013 (Wolff 2007; 2013). The guideline was established to promote complete and standardized reporting of malignant pathology to "Improve the accuracy of HER2 testing and its utility as a predictive marker in invasive breast cancer" (Wolff, 2013). The guideline recommends all individuals with newly diagnosed and recurrent invasive breast cancer should have tumors HER2 tested by laboratories that are accredited to perform HER2 testing. The updated guideline defines the results of HER2 testing as follows:
Negative HER2 if a single test (or both tests) performed show:
For individuals with equivocal results, the guidelines (Wolff, 2013) recommend additional testing with a reflex test (on the same specimen using the alternative test) or a new test (new specimen if available, using same or alternative test).
NCCN guidelines for breast cancer (2014) have incorporated the updated ASCO/CAP recommendations for HER2 status into the treatment algorithms for HER2 targeted therapy.
Specific IHC scoring criteria were developed for gastric carcinoma based on the identification of basolateral membrane staining of gastric tumor specimens obtained surgically or via biopsy. Staining of surgical specimens with "strong complete, basolateral or lateral membranous reactivity in ≥ 10% of tumor cells" was deemed IHC 3+ and HER2 positive (Bang, 2010). Staining of biopsy specimens with "tumor cell cluster with a strong complete, basolateral or lateral membranous reactivity irrespective of percentage of tumor cells stained" were deemed IHC 3+ and HER2 positive (Bang, 2010). Equivocal results were categorized as IHC 2+ with staining of surgical specimens "weak to moderate complete, basolateral or lateral membranous reactivity in ≥ 10% of tumor cells" (Bang, 2010). Equivocal HER2 was determined if staining on biopsy specimens included "cancer cell cluster with a weak to moderate complete, basolateral, or lateral membranous reactivity irrespective of percentage of cancer cells" was HER2 equivocal (Bang, 2010).
Trastuzumab is associated with a risk of cardiac dysfunction. The practice guidelines from the NCCN (2014) recommend baseline cardiac monitoring and intermittent cardiac function testing during the course of therapy. Additionally, the product label states treatment with trastuzumab should only start or continue if the left ventricular ejection fraction (LVEF) is above the institutional lower limit of normal. Jones and colleagues (2009) noted "patients with metastatic disease have a very different oncology risk profile to those receiving adjuvant treatment; the monitoring strategy and thresholds for treatment discontinuation should thus be individualized in consultation with the oncologist and cardiologist when appropriate."
As a result of clinical trials demonstrating the effectiveness of trastuzumab with chemotherapy, additional clinical trials are studying the efficacy of adding trastuzumab to specific targeted biologic agents. However, at this time, there is no evidence to support the safety and efficacy of combining trastuzumab with other biologic agents not discussed above.
The NCCN clinical practice guideline for non-small cell lung cancer notes trastuzumab may be used as a targeted agent for individuals with HER2 mutations. However, the evidence cited to support the 2A off-label indication is limited to a case report. The National Cancer Institute (NCI) notes the incidence of HER2-positive NSCLC is less than 2% (NCI, 2014). Two randomized phase II studies investigating trastuzumab in combination with chemotherapy to treat NSCLC did not observe clinically significant benefit of adding trastuzumab to the standard chemotherapeutic regimens (Gatzemeier, 2004; Krug, 2005). The NCI does not recommend trastuzumab as a treatment for NSCLC (2014).
The Children's Oncology Group reported results from a phase 2 trial of combination therapy of trastuzumab and chemotherapy as a treatment for high-risk osteosarcoma with HER2 over-expression (Ebb, 2012). Of the 96 evaluable individuals with newly diagnosed metastatic osteosarcoma, 41 individuals had HER2-positive tumors. All participants received 10 weeks of induction therapy with doxorubicin, cisplatin, methotrexate, ifosfamide, and etoposide followed by 21 weeks of postinduction therapy. Those with HER2-positive tumors received trastuzumab for a total of 34 doses. At a median follow-up of 41.6 months, there were no statistically significant differences in OS and event-free survival (EFS) between the HER2-positive and the HER2-negative cohorts. The 30-month EFS was 32% (95% CI, 18% to 46%), with 30-month OS of 59% (95% CI, 43% to 73%) in the group with HER2-positive tumors and who received trastuzumab therapy. The HER2-negative group had a 30-month EFS of 32% (95% CI, 20% to 45%) with a 30-month OS of 50% (95% CI, 36% to 63%). Ebb and colleagues (2012) noted there is "controversy regarding the reliability, consistency, and predictive value of HER2 expression levels in osteosarcoma." There is currently an ongoing study to determine if HER2 has a prognostic impact for osteosarcoma. The researchers noted the consistent validation of HER2 expression in osteosarcoma also needs to be established, and then a randomized controlled trial should be done to compare the effects of treatment with trastuzumab versus without trastuzumab.
In a phase 2 study of 212 individuals with metastatic pancreatic cancer, Harder and colleagues (2012) investigated the significance of HER2 expression and the potential use of trastuzumab as an agent to target HER2 overexpression when given in combination with capecitabine. The single-arm, open-label trial screened 212 individuals at nine different institutions. Tumor specimens were available for HER2 expression and gene amplification testing in 207 participants, of which 22 (11%) had IHC grade 3. Seventeen participants with HER2 IHC 3+ were eligible for assessment after 12 weeks of treatment. Progressive disease (PD) occurred in 13 of the 17 participants, with a primary endpoint of PFS rate estimated after 12 weeks of 23.5%. The study was terminated early with four participants alive and without evidence of PD after 12 weeks. In a post hoc FISH analysis of the IHC 3+ pancreatic tumor tissue, the HER2 gene amplification was inconsistent and contrary to other tumor types such as breast and gastric cancer. The authors concluded the HER2 gene amplification in pancreatic cancer was very low and OS and PFS were not improved with treatment of trastuzumab and capecitabine. Therefore "further evaluation of anti-HER2 treatment in patients with metastatic pancreatic cancer" was not recommended (Harder, 2012).
Additionally, investigators continue to study the prevalence and role of HER2 in other malignancies. However, there have been no large randomized controlled trials demonstrating the safety and efficacy of trastuzumab versus current standard therapies for malignancies other than breast, gastric, esophageal and gastroesophageal cancers.
The human epidermal growth factor receptor 2 gene ERBB2 is commonly referred to as HER2. Other names for this gene include NEU, Her-2, HER-2/neu and c-erb B2. Initially, the HER2 gene was detected in frozen breast tumor samples. Amplification of the HER2 gene was later correlated to overexpression of protein levels in samples of breast cancer. The HER2 overexpression is present in approximately 18%-25% of all early breast cancers and is associated with aggressive disease, shortened DFS and OS (Baselga, 2006; Robert, 2006; Wolff, 2007; Wolff, 2013).
According to the National Cancer Institute (NCI, 2014), approximately 10% to 20% of all new gastric cancer cases are diagnosed at an early stage of disease. The remaining individuals are diagnosed with regional or distant metastatic disease. A review by Gravalos (2008) noted HER2 overexpression in gastric cancer ranged from 9% - 38% in reported series.
Adverse Events and Warnings:
The Product Information Label (2014) for trastuzumab includes the following Black Box warnings:
Herceptin administration can result in sub-clinical and clinical cardiac failure. The incidence and severity was highest in patients receiving Herceptin with anthracycline containing chemotherapy regimens. Evaluate left ventricular function in all patients prior to and during treatment with Herceptin. Discontinue Herceptin treatment in patients receiving adjuvant therapy and withhold Herceptin in patients with metastatic disease for clinically significant decrease in left ventricular function.
Infusion Reactions; Pulmonary Toxicity
Herceptin administration can result in serious and fatal infusion reactions and pulmonary toxicity. Symptoms usually occur during or within 24 hours of Herceptin administration. Interrupt Herceptin infusion for dyspnea or clinically significant hypotension. Monitor patients until symptoms completely resolve. Discontinue Herceptin for anaphylaxis, angioedema, interstitial pneumonitis, or acute respiratory distress syndrome.
Exposure to Herceptin during pregnancy can result in oligohydramnios and oligohydramnios sequence manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death.
Other serious adverse reactions caused by trastuzumab include diarrhea, exacerbation of chemotherapy-induced neutropenia and infection.
Adjuvant therapy: Treatment given after the primary treatment to increase the chances of a cure; may include chemotherapy, radiation, hormone or biological therapy.
Anti-HER2 therapy: Agents that target the HER2 receptor (for example, lapatinib, pertuzumab, and trastuzumab).
Disease free survival (DFS): The interval between a complete disappearance of the cancer (complete response) and the time of relapse.
Line of therapy:
Metastatic: The spread of cancer from one part of the body to another. A metastatic tumor contains cells that are like those in the original (primary) tumor and have spread.
Monoclonal antibody: A protein developed in the laboratory that can locate and bind to specific substances in the body and on the surface of cancer cells.
Neoadjuvant therapy: Treatment given before the primary treatment which may include chemotherapy, radiation therapy, or hormone therapy.
Off-label: Utilization of a United States Food and Drug Administration (FDA) approved drug for uses other than those listed in the FDA approved label.
Targeted biologic agent: A newer type of drug developed specifically to target genetic changes in cells that cause cancer. It works differently than standard chemotherapy drugs, often with different side effects.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
|J9355||Injection; trastuzumab, 10 mg [Herceptin]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|150.0-150.9||Malignant neoplasm of esophagus|
|151.0-151.9||Malignant neoplasm of stomach|
|174.0-174.9||Malignant neoplasm of female breast|
|175.0-175.9||Malignant neoplasm of male breast|
|197.8||Secondary malignant neoplasm of other digestive organs and spleen [specified as esophagus or stomach]|
|198.81||Secondary malignant neoplasm of breast|
|233.0||Carcinoma in situ of breast|
|V58.11-V58.12||Encounter for antineoplastic chemotherapy and immunotherapy|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|C15.3-C15.9||Malignant neoplasm of esophagus|
|C16.0-C16.9||Malignant neoplasm of stomach|
|C50.011-C50.929||Malignant neoplasm of breast|
|C78.89||Secondary malignant neoplasm of other digestive organs [specified as esophagus or stomach]|
|C79.81||Secondary malignant neoplasm of breast|
|D00.1||Carcinoma in situ of esophagus|
|D00.2||Carcinoma in situ of stomach|
|D05.00-D05.92||Carcinoma in situ of breast|
|Z51.11-Z51.12||Encounter for antineoplastic chemotherapy and immunotherapy|
|Z85.3||Personal history of malignant neoplasm of breast|
When services are Investigational and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, for all other diagnoses not listed or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Revised||05/15/2014||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||05/14/2014||Hematology/Oncology Subcommittee review. Revised HER2-positivity and how it is measured. Revised order of medically necessary breast cancer criteria and added the words "as a component of" prior to neoadjuvant therapy. Clarified criteria addressing combination therapy with pertuzumab for breast cancer by removing the word "metastatic." Updated Rationale, References and Websites sections.|
|Revised||05/08/2013||Hematology/Oncology Subcommittee review. Clarified medically necessary HER2 positive FISH criteria for both breast and gastric/GE adenocarcinoma to "greater than or equal to 2.0." Added "advanced" to gastric/GE criterion. Updated Rationale, References and Websites.|
|Revised||11/07/2012||Hematology/Oncology Subcommittee review. Clarified medically necessary criteria for combination therapy with FDA approved pertuzumab to treat metastatic breast cancer. Updated Rationale and References.|
|Revised||06/19/2012||Hematology/Oncology Subcommittee review. Added medically necessary criteria for combination therapy with new FDA approved pertuzumab to treat metastatic breast cancer. Updated Rationale and References.|
|Revised||05/09/2012||Hematology/Oncology Subcommittee review. Clarified FISH ratio of HER2 gene/chromosome 17 ratio is greater than 2.0. Clarified neoadjuvant therapy. Removed criteria for baseline cardiac testing. Formatting changes to the Position Statements. Updated Rationale, Definitions, References and Websites. On 6/19/2012,|
|Revised||05/18/2011||Hematology/Oncology Subcommittee review. Clarified medically necessary statement for breast cancer. Modified cardiac medically necessary statements. Updated Rationale, References and Websites.|
|Revised||11/17/2010||Hematology/Oncology Subcommittee review. Clarified adjuvant therapy for breast cancer. Updated Rationale, References and Websites.|
|Revised||05/12/2010||Hematology/Oncology Subcommittee review. Clarified HER2 testing criteria. Added medically necessary criteria for esophageal and gastroesophageal junction. Added medically necessary lapatinib combination with criteria. Deleted lapatinib from investigational and not medically necessary criteria. Updated Rationale, Coding, References and Websites.|
|Revised||11/18/2009||Hematology/Oncology Subcommittee review. Revised cardiac criteria. Removed redundant medical necessary criteria for adjuvant breast cancer therapy. Updated rationale, references and websites.|
|Revised||06/17/2009||Hematology/Oncology Subcommittee review. Added criteria for gastric cancer. Updated rationale, background and coding.|
|Revised||05/20/2009||Hematology/Oncology Subcommittee review. Updated rationale, references, definitions and websites. Removed redundant adjuvant medically necessary criteria.|
|Revised||01/13/2009||Hematology/Oncology Subcommittee review. Removed tumor criteria in node-negative, adjuvant setting.|
|New||05/14/2008||Hematology/Oncology Subcommittee review. Converted from CG-DRUG-02 Trastuzumab (Herceptin®).|