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Opdivo Qvantig™ (nivolumab and hyaluronidase-nvhy)

Policy Number: VP-0784

(Subcutaneous)

 

Last Review Date: 02/04/2025

Date of Origin: 02/04/2025

Dates Reviewed: 02/2025

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.
  1. Length of Authorization ∆ 1

Coverage will be provided for 6 months and may be renewed (unless otherwise specified).

  • Neoadjuvant treatment of NSCLC without adjuvant treatment may be authorized for a maximum of three (3) neoadjuvant doses
  • Neoadjuvant treatment followed by optional adjuvant treatment of NSCLC may be authorized for a maximum of four (4) neoadjuvant doses and thirteen (13) adjuvant doses.
  • Adjuvant treatment of the following indications may be renewed up to a maximum of one (1) year of therapy*:
    • Cutaneous Melanoma (single agent)
    • Esophageal and Esophagogastric/Gastroesophageal Junction Cancer
    • Urothelial Carcinoma
  • The following indications may be renewed up to a maximum of two (2) years of therapy:
    • Esophageal Squamous Cell Carcinoma
    • Esophageal and Esophagogastric/Gastroesophageal Junction Cancer
    • Gastric Cancer
    • Renal Cell Carcinoma (in combination with cabozantinib)
    • Urothelial Carcinoma (first line therapy in combination with gemcitabine and cisplatin, followed by single-agent maintenance therapy)
  2. Dosing Limits

*Note: The maximum number of doses is dependent on the dosing frequency and duration of therapy. Refer to Section V for exact dosage.

Dosing Frequency

Maximum length of therapy

Maximum number of doses

2 weeks

1 year

26 doses

2 years

52 doses

3 weeks

2 years

35 doses

4 weeks

1 year

13 doses

2 years

26 doses
  1. Max Units (per dose and over time) [HCPCS Unit]:
    • 1,200 mg/20,000 units every 4 weeks
  1. Initial Approval Criteria 1

Coverage is provided in the following conditions:

  • Patient is at least 18 years of age; AND

Universal Criteria

  • Patient has not received previous therapy with a programmed death (PD-1/PD-L1)-directed therapy (e.g., atezolizumab, pembrolizumab, durvalumab, avelumab, cemiplimab, dostarlimab, nivolumab/relatlimab, retifanlimab, toripalimab, tislelizumab, etc.) unless otherwise specified ∆ (Note: Not applicable when used as switch-therapy with intravenous nivolumab); AND
  • Therapy will not be used concomitantly with intravenous nivolumab; AND
  • IV formulation of Opdivo must be used in the following:
    • Patients <80 kg; OR
    • Patients requiring 900 mg/15,000 units dose*; OR
    • Patients receiving therapy in combination with ipilimumab; AND

Urothelial Carcinoma (Bladder Cancer) †  1,2,30,51,62,92

  • Used as a single agent; AND
    • Used for disease that progressed during or following platinum-containing chemotherapy* OR progression with 12 months of neoadjuvant or adjuvant treatment with a platinum-containing regimen; OR
    • Used as adjuvant therapy in patients who are at a high risk for disease recurrence after undergoing surgical resection; OR
  • Used in combination with cisplatin and gemcitabine; AND
    • Used as first line therapy in patient with unresectable or metastatic disease

** Note: 1,62

  • High risk for disease recurrence is defined as:
  • ypT2-ypT4a or ypN+ for patients who received neoadjuvant cisplatin (excluding prostate with stromal invasion); OR
  • pT3-pT4a or pN+ for patients who did not receive neoadjuvant cisplatin and are also ineligible for or refused adjuvant cisplatin therapy (excluding ureter or renal pelvis)

Colorectal Cancer (CRC) † ‡ 1,2,31,32

  • Patient has microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR) disease as determined by an FDA-approved or CLIA-compliant testv; AND
  • Used as a single agent; AND
  • Used as subsequent therapy for metastatic disease; AND
  • Patient has disease progression following treatment with a fluoropyrimidine, oxaliplatin and irinotecan regimen

Gastric Cancer/Esophageal Cancer/Gastroesophageal Junction (GEJ) Cancer † 1,2,44,52,56,69

  • Used as a single agent; AND
      • Used as adjuvant treatment of completely resected esophageal or GEJ cancer with residual pathologic disease in patients who have received neoadjuvant chemoradiotherapy (CRT).; OR
      • Used as subsequent therapy after prior fluoropyrimidine- and platinum-based chemotherapy; AND
        • Used for unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma (ESCC); OR
  • Used in combination with fluoropyrimidine- and platinum-containing chemotherapy; AND
      • Used as first-line therapy; AND
        • Used in patients with unresectable, advanced or metastatic esophageal squamous cell carcinoma (ESCC); OR
        • Used for advanced or metastatic gastric, GEJ, or esophageal adenocarcinomas

Squamous Cell Carcinoma of the Head and Neck (SCCHN) † 1,2,29,78

  • Used as single-agent therapy; AND
  • Patient has metastatic disease with disease progression on or after platinum-based therapy; AND
  • Patient does not have disease of the nasopharynx

Hepatocellular Carcinoma (HCC) † 1,2,21,86,87

  • Used as a single agent; AND
  • Patient was previously treated with sorafenib following treatment with nivolumab/ipilimumab

Renal Cell Carcinoma (RCC) † 1,2,25,26

  • Used as a single agent; AND
    • Used as first line therapy in patients with intermediate or poor risk disease following previous treatment with nivolumab and ipilimumab combination therapy; OR
    • Used as subsequent therapy after prior anti-angiogenic therapy; OR
  • Used in combination with cabozantinib (Cabometyx only); AND
    • Used as first-line therapy for advanced disease

Cutaneous Melanoma † 1,2,15-18,82,93

  • Used as single agent therapy; AND
    • Used as first-line therapy for unresectable or metastatic disease; OR
    • Used as subsequent therapy for unresectable or metastatic disease after prior nivolumab/ipilimumab combination therapy; OR
  • Used as adjuvant treatment and patient has stage IIB, stage IIC, stage III or metastatic disease and has undergone complete resection

Non-Small Cell Lung Cancer (NSCLC) † 1,2,22,23,43,45,46

  • Used as single-agent therapy; AND
    • Used for metastatic disease; AND
    • Used as subsequent therapy on or after platinum-based chemotherapy (Note: Patients with EGFR or ALK genomic tumor aberrations should have disease progression on targeted therapies prior to receiving Opdivo Qvantig); OR
  • Used in combination with platinum-doublet chemotherapy; AND
    • Used as neoadjuvant therapy in patients who have resectable (tumors ≥ 4 cm or node positive) disease; OR
  • Used as neoadjuvant therapy in resectable disease with the option of continuing to single-agent Opdivo Qvantig therapy as adjuvant treatment after surgery

vIf confirmed using an FDA approved assay – http://www.fda.gov/companiondiagnostics

† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug

§ Genomic Aberration/Mutational Driver Targeted Therapies

(Note: not all inclusive, refer to guidelines for appropriate use)

EGFR exon 19 deletion or exon 21 L858R tumors

EGFR S768I, L861Q, and/or G719X mutation positive tumors

EGFR exon 20 insertion mutation positive tumors

NTRK1/2/3 gene fusion positive tumors
  • Afatinib
  • Erlotinib
  • Dacomitinib
  • Gefitinib
  • Osimertinib
  • Amivantamab
  • Afatinib
  • Erlotinib
  • Dacomitinib
  • Gefitinib
  • Osimertinib
  • Amivantamab
  • Amivantamab
  • Larotrectinib
  • Entrectinib
  • Repotrectinib

ALK rearrangement-positive tumors

ROS1 rearrangement-positive tumors

BRAF V600E-mutation positive tumors

ERBB2 (HER2) mutation positive tumors
  • Alectinib
  • Brigatinib
  • Ceritinib
  • Crizotinib
  • Lorlatinib
  • Ceritinib
  • Crizotinib 
  • Entrectinib
  • Lorlatinib
  • Repotrectinib
  • Dabrafenib ± trametinib
  • Encorafenib + binimetinib
  • Vemurafenib
  • Fam-trastuzumab deruxtecan-nxki
  • Ado-trastuzumab emtansine

PD-L1 tumor

expression ≥ 1%

MET exon-14 skipping mutations

RET rearrangement-positive tumors

KRAS G12C mutation positive tumors
  • Pembrolizumab
  • Atezolizumab
  • Nivolumab + ipilimumab
  • Cemiplimab
  • Tremelimumab + durvalumab
  • Capmatinib
  • Crizotinib
  • Tepotinib
  • Selpercatinib
  • Cabozantinib
  • Pralsetinib
  • Sotorasib
  • Adagrasib
  1. Renewal Criteria ∆ 1,6

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
  • Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: immune-mediated adverse reactions (e.g., pneumonitis, hepatitis, colitis, endocrinopathies, nephritis/renal dysfunction, rash/dermatitis [including Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS), and toxic epidermal necrolysis (TEN)], myocarditis, pericarditis, vasculitis, solid organ transplant rejection, etc.), severe infusion-related reactions, complications of allogeneic hematopoietic stem cell transplantation (HSCT), etc.

NSCLC (neoadjuvant/adjuvant treatment)

  • Patient has not exceeded a maximum of twelve (12) months (13 cycles) of therapy

Δ Notes:

  • Patients responding to therapy who relapse ≥ 6 months after discontinuation due to duration are eligible to re-initiate PD-directed therapy.
  • Patients previously presenting with aggressive disease who are exhibiting stable disease on treatment as their best response (or if therapy improved performance status) may be eligible for continued therapy without interruption or discontinuation.
  • Patients who complete adjuvant therapy and progress ≥ 6 months after discontinuation are eligible to re-initiate PD-directed therapy for metastatic disease.
  • Patients whose tumors, upon re-biopsy, demonstrate a change in actionable mutation (e.g., MSS initial biopsy; MSI-H subsequent biopsy) may be eligible to re-initiate PD-directed therapy and will be evaluated on a case-by-case basis.

  1. Dosage/Administration ∆ 1,14,27,28

Indication

Dose

Renal Cell Carcinoma
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks administered in combination with cabozantinib 40 mg once daily without food, up to a maximum of 2 years of therapy.

Melanoma
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.

Note: For adjuvant therapy, treat until disease recurrence or unacceptable toxicity for up to 1 year

NSCLC

Neoadjuvant and adjuvant treatment

    • * 900 mg/15,000 units with platinum-doublet chemotherapy on the same day every 3 weeks for 3 cycles, then single-agent Opdivo Qvantig 1,200 mg/20,000 units every 4 weeks after surgery for up to 13 cycles.

Metastatic non-small cell lung cancer

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.

SCCHN
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.

Urothelial Carcinoma

Urothelial carcinoma

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.

Note: For adjuvant therapy, treat until disease recurrence or unacceptable toxicity for up to 1 year

First-line unresectable or metastatic urothelial carcinoma

    • * 900 mg/15,000 units every 3 weeks with cisplatin and gemcitabine on the same day for up to 6 cycles, then 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, up to a maximum of 2 years of therapy.

Colorectal Carcinoma
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.

Hepatocellular Carcinoma
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity.

Esophageal Squamous Cell Cancer
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity. OR
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks administered in combination with fluoropyrimidine- and platinum-containing chemotherapy, up to a maximum of 2 years of therapy.

Gastric Cancer, GEJ Cancer, and Esophageal Adenocarcinoma
    • 600 mg/10,000 units every 2 weeks in combination with fluoropyrimidine- and platinum-containing chemotherapy every 2 weeks, up until a maximum of 2 years of therapy.
    • * 900 mg/15,000 units every 3 weeks with fluoropyrimidine- and platinum containing chemotherapy every 3 weeks, up until a maximum of 2 years of therapy.

Note: For adjuvant therapy in esophageal and GEJ, treat until disease recurrence or unacceptable toxicity for up to 1 year

Note:

  • *The 900 mg/15,000 units dosing is listed in the prescribing information; however, the IV formulation of nivolumab must be used instead to prevent wastage.
  • Opdivo Qvantig (nivolumab and hyaluronidase-nvhy) has different dosage and administration instructions than intravenous nivolumab products.
  • Opdivo Qvantig is for subcutaneous use only in the abdomen or thigh.
  • Opdivo Qvantig is to be administered by a healthcare professional only.
  • Opdivo Qvantig is for subcutaneous use only administered over 3-5 minutes.
  1. Billing Code/Availability Information

HCPCS Code:

  • J9999 – Not otherwise classified, antineoplastic drugs
  • C9399 – Unclassified drugs or biologicals (hospital outpatient use only)

NDC(s):

  • Opdivo Qvantig single-dose vial providing 600 mg nivolumab and 10,000 units hyaluronidase per 5 mL (120 mg/ 2,000 units per mL): 00003-6120-xx
  1. References
  1. Opdivo Qvantig [package insert]. Princeton, NJ; Bristol-Myers Squibb, Inc; December 2024. Accessed January 2025.
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Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

C00.0

Malignant neoplasm of external upper lip

C00.1

Malignant neoplasm of external lower lip

C00.2

Malignant neoplasm of external lip, unspecified

C00.3

Malignant neoplasm of upper lip, inner aspect

C00.4

Malignant neoplasm of lower lip, inner aspect

C00.5

Malignant neoplasm of lip, unspecified, inner aspect

C00.6

Malignant neoplasm of commissure of lip, unspecified

C00.8

Malignant neoplasm of overlapping sites of lip

C00.9

Malignant neoplasm of lip, unspecified

C01

Malignant neoplasm of base of tongue

C02.0

Malignant neoplasm of dorsal surface of tongue

C02.1

Malignant neoplasm of border of tongue

C02.2

Malignant neoplasm of ventral surface of tongue

C02.3

Malignant neoplasm of anterior two-thirds of tongue, part unspecified

C02.4

Malignant neoplasm of lingual tonsil

C02.8

Malignant neoplasm of overlapping sites of tongue

C02.9

Malignant neoplasm of tongue, unspecified

C03.0

Malignant neoplasm of upper gum

C03.1

Malignant neoplasm of lower gum

C03.9

Malignant neoplasm of gum, unspecified

C04.0

Malignant neoplasm of anterior floor of mouth

C04.1

Malignant neoplasm of lateral floor of mouth

C04.8

Malignant neoplasm of overlapping sites of floor of mouth

C04.9

Malignant neoplasm of floor of mouth, unspecified

C05.0

Malignant neoplasm of hard palate

C05.1

Malignant neoplasm of soft palate

C05.8

Malignant neoplasm of overlapping sites of palate

C05.9

Malignant neoplasm of palate, unspecified

C06.0

Malignant neoplasm of cheek mucosa

C06.2

Malignant neoplasm of retromolar area

C06.80

Malignant neoplasm of overlapping sites of unspecified parts of mouth

C06.89

Malignant neoplasm of overlapping sites of other parts of mouth

C06.9

Malignant neoplasm of mouth, unspecified

C09.0

Malignant neoplasm of tonsillar fossa

C09.1

Malignant neoplasm of tonsillar pillar (anterior) (posterior)

C09.8

Malignant neoplasm of overlapping sites of tonsil

C09.9

Malignant neoplasm of tonsil, unspecified

C10.0

Malignant neoplasm of vallecula

C10.1

Malignant neoplasm of anterior surface of epiglottis

C10.2

Malignant neoplasm of lateral wall of oropharynx

C10.3

Malignant neoplasm of posterior wall of oropharynx

C10.4

Malignant neoplasm of branchial cleft

C10.8

Malignant neoplasm of overlapping sites of oropharynx

C10.9

Malignant neoplasm of oropharynx, unspecified

C11.0

Malignant neoplasm of superior wall of nasopharynx

C11.1

Malignant neoplasm of posterior wall of nasopharynx

C11.2

Malignant neoplasm of lateral wall of nasopharynx

C11.3

Malignant neoplasm of anterior wall of nasopharynx

C11.8

Malignant neoplasm of overlapping sites of nasopharynx

C11.9

Malignant neoplasm of nasopharynx, unspecified

C12

Malignant neoplasm of pyriform sinus

C13.0

Malignant neoplasm of postcricoid region

C13.1

Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect

C13.2

Malignant neoplasm of posterior wall of hypopharynx

C13.8

Malignant neoplasm of overlapping sites of hypopharynx

C13.9

Malignant neoplasm of hypopharynx, unspecified

C14.0

Malignant neoplasm of pharynx, unspecified

C14.2

Malignant neoplasm of Waldeyer’s ring

C14.8

Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C15.3

Malignant neoplasm of upper third of esophagus

C15.4

Malignant neoplasm of middle third of esophagus

C15.5

Malignant neoplasm of lower third of esophagus

C15.8

Malignant neoplasm of overlapping sites of esophagus

C15.9

Malignant neoplasm of esophagus, unspecified

C16.0

Malignant neoplasm of cardia

C16.1

Malignant neoplasm of fundus of stomach

C16.2

Malignant neoplasm of body of stomach

C16.3

Malignant neoplasm of pyloric antrum

C16.4

Malignant neoplasm of pylorus

C16.5

Malignant neoplasm of lesser curvature of stomach, unspecified

C16.6

Malignant neoplasm of greater curvature of stomach, unspecified

C16.8

Malignant neoplasm of overlapping sites of stomach

C16.9

Malignant neoplasm of stomach, unspecified

C18.0

Malignant neoplasm of cecum

C18.2

Malignant neoplasm of ascending colon

C18.3

Malignant neoplasm of hepatic flexure

C18.4

Malignant neoplasm of transverse colon

C18.5

Malignant neoplasm of splenic flexure

C18.6

Malignant neoplasm of descending colon

C18.7

Malignant neoplasm of sigmoid colon

C18.8

Malignant neoplasm of overlapping sites of colon

C18.9

Malignant neoplasm of colon, unspecified

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C22.0

Liver cell carcinoma

C22.8

Malignant neoplasm of liver, primary, unspecified as to type

C22.9

Malignant neoplasm of liver, not specified as primary or secondary

C30.0

Malignant neoplasm of nasal cavity

C31.0

Malignant neoplasm of maxillary sinus

C31.1

Malignant neoplasm of ethmoidal sinus

C32.0

Malignant neoplasm of glottis

C32.1

Malignant neoplasm of supraglottis

C32.2

Malignant neoplasm of subglottis

C32.3

Malignant neoplasm of laryngeal cartilage

C32.8

Malignant neoplasm of overlapping sites of larynx

C32.9

Malignant neoplasm of larynx, unspecified

C33

Malignant neoplasm of trachea

C34.00

Malignant neoplasm of unspecified main bronchus

C34.01

Malignant neoplasm of right main bronchus

C34.02

Malignant neoplasm of left main bronchus

C34.10

Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11

Malignant neoplasm of upper lobe, right bronchus or lung

C34.12

Malignant neoplasm of upper lobe, left bronchus or lung

C34.2

Malignant neoplasm of middle lobe, bronchus or lung

C34.30

Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31

Malignant neoplasm of lower lobe, right bronchus or lung

C34.32

Malignant neoplasm of lower lobe, left bronchus or lung

C34.80

Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81

Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82

Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90

Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91

Malignant neoplasm of unspecified part of right bronchus or lung

C34.92

Malignant neoplasm of unspecified part of left bronchus or lung

C43.0

Malignant melanoma of lip

C43.111

Malignant melanoma of right upper eyelid, including canthus

C43.112

Malignant melanoma of right lower eyelid, including canthus

C43.121

Malignant melanoma of left upper eyelid, including canthus

C43.122

Malignant melanoma of left lower eyelid, including canthus

C43.20

Malignant melanoma of unspecified ear and external auricular canal

C43.21

Malignant melanoma of right ear and external auricular canal

C43.22

Malignant melanoma of left ear and external auricular canal

C43.30

Malignant melanoma of unspecified part of face

C43.31

Malignant melanoma of nose

C43.39

 Malignant melanoma of other parts of face

C43.4

Malignant melanoma of scalp and neck

C43.51

Malignant melanoma of anal skin

C43.52

Malignant melanoma of skin of breast

C43.59

Malignant melanoma of other part of trunk

C43.60

Malignant melanoma of unspecified upper limb, including shoulder

C43.61

Malignant melanoma of right upper limb, including shoulder

C43.62

Malignant melanoma of left upper limb, including shoulder

C43.70

Malignant melanoma of unspecified lower limb, including hip

C43.71

Malignant melanoma of right lower limb, including hip

C43.72

Malignant melanoma of left lower limb, including hip

C43.8

Malignant melanoma of overlapping sites of skin

C43.9

Malignant melanoma of skin, unspecified

C44.00

Unspecified malignant neoplasm of skin of lip

C44.02

Squamous cell carcinoma of skin of lip

C44.09

Other specified malignant neoplasm of skin of lip

C64.1

Malignant neoplasm of right kidney, except renal pelvis

C64.2

Malignant neoplasm of left kidney, except renal pelvis

C64.9

Malignant neoplasm of unspecified kidney, except renal pelvis

C65.1

Malignant neoplasm of right renal pelvis

C65.2

Malignant neoplasm of left renal pelvis

C65.9

Malignant neoplasm of unspecified renal pelvis

C66.1

Malignant neoplasm of right ureter

C66.2

Malignant neoplasm of left ureter

C66.9

Malignant neoplasm of unspecified ureter

C67.0

Malignant neoplasm of trigone of bladder

C67.1

Malignant neoplasm of dome of bladder

C67.2

Malignant neoplasm of lateral wall of bladder

C67.3

Malignant neoplasm of anterior wall of bladder

C67.4

Malignant neoplasm of posterior wall of bladder

C67.5

Malignant neoplasm of bladder neck

C67.6

Malignant neoplasm of ureteric orifice

C67.7

Malignant neoplasm of urachus

C67.8

Malignant neoplasm of overlapping sites of bladder

C67.9

Malignant neoplasm of bladder, unspecified

C68.0

Malignant neoplasm of urethra

C76.0

Malignant neoplasm of head, face and neck

C77.0

Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck

C78.00

Secondary malignant neoplasm of unspecified lung

C78.01

Secondary malignant neoplasm of right lung

C78.02

Secondary malignant neoplasm of left lung

C78.6

Secondary malignant neoplasm of retroperitoneum and peritoneum

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

D09.0

Carcinoma in situ of bladder

D37.01

Neoplasm of uncertain behavior of lip

D37.02

Neoplasm of uncertain behavior of tongue

D37.05

Neoplasm of uncertain behavior of pharynx

D37.09

Neoplasm of uncertain behavior of other specified sites of the oral cavity

D37.1

Neoplasm of uncertain behavior of stomach

D37.8

Neoplasm of uncertain behavior of other specified digestive organs

D37.9

Neoplasm of uncertain behavior of digestive organ, unspecified

D38.0

Neoplasm of uncertain behavior of larynx

D38.5

Neoplasm of uncertain behavior of other respiratory organs

D38.6

Neoplasm of uncertain behavior of respiratory organ, unspecified

Z85.00

Personal history of malignant neoplasm of unspecified digestive organ

Z85.01

Personal history of malignant neoplasm of esophagus

Z85.028

Personal history of other malignant neoplasm of stomach

Z85.118

Personal history of other malignant neoplasm of bronchus and lung

Z85.51

Personal history of malignant neoplasm of bladder

Z85.59

Personal history of malignant neoplasm of other urinary tract organ

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A

 

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC