Therefore, Aetna considers Fulphila, Fylnetra, Nyvepria, Rolvedon, Stimufend, and Udenyca to be medically necessary only for members who have a contraindication, intolerance or ineffective response to the available equivalent alternative long-acting Hematopoietic Colony Stimulating Factors: Neulasta, Neulasta Onpro, and Ziextenzo. There is a lack of reliable evidence that Fulphila, Fylnetra, Nyvepria, Rolvedon, Stimufend, and Udenyca are superior to the lower cost long-acting Hematopoietic Colony Stimulating Factors: Neulasta, Neulasta Onpro, and Ziextenzo. Fulphila, Fylnetra, Nyvepria, Rolvedon, Stimufend, and Udenyca are more costly to Aetna than other long-acting Hematopoietic Colony Stimulating Factors. For Leukine: Member has had a documented inadequate response or an intolerable adverse event to the least costly product, Zarxio.Īs defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results.For Granix, Neupogen, Nivestym, or Releuko: Member has failed treatment with Zarxio due to a documented intolerable adverse event (e.g., rash, nausea, vomiting) and the adverse event was not an expected adverse event attributed to the active ingredient as described in the prescribing information.Therefore, Aetna considers Granix, Leukine, Neupogen, Nivestym, and Releuko to be medically necessary only for members who have a contraindication, intolerance or ineffective response to the available equivalent alternative short-acting Hematopoietic Colony Stimulating Factor: Zarxio per criteria below:
There is a lack of reliable evidence that Granix, Leukine, Neupogen, Nivestym, and Releuko are superior to the lower cost short-acting Hematopoietic Colony Stimulating Factor: Zarxio. Granix, Leukine, Neupogen, Nivestym, and Releuko are more costly to Aetna than other short-acting Hematopoietic Colony Stimulating Factors. Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References Brand Selection for Medically Necessary IndicationsĪs defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results.
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