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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. 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.

SUPERSEDED BY CURRENT VERSION

Effective: 04/15/17

Updated: 05/15/17

09-J2000-22

Original Effective Date: 11/15/14

Reviewed: 01/11/17

Revised: 04/15/17

Subject: Pembrolizumab (Keytruda®) Injection

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Dosage/ Administration Position Statement Billing/Coding Reimbursement Program Exceptions Definitions
           
Related Guidelines Other References Updates  
           

DESCRIPTION:

Pembrolizumab (Keytruda) was approved by the U.S. Food and Drug Administration (FDA) in September 2014 for treatment of unresectable or metastatic melanoma. Pembrolizumab was granted FDA approval in October 2015 for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors express programmed death ligand 1 (PD-L1) with a Tumor Proportion Score (TPS) greater than or equal to 1% and who have disease progression on or after platinum-containing chemotherapy. Additionally, the product is approved for use in patients with metastatic NSCLC epithelial growth factor receptor (EGFR) mutations or anaplastic lymphoma kinase (ALK) gene rearrangements in patients who have disease progression on FDA-approved targeted therapy prior to receiving pembrolizumab. A companion diagnostic test was approved to detect PD-L1 expression in non-small cell lung tumors. The FDA expanded the use in metastatic NSCLC for the treatment of tumors with high-PD-L1 expression (TPS greater than or equal to 50%) with no prior systemic chemotherapy and no EGFR or ALK genomic tumor aberrations. Pembrolizumab was FDA-approved in August 2016 for patients with recurrent or metastatic squamous cell carcinoma of the head and neck with disease progression on or after platinum-containing chemotherapy. This indication is approved under accelerated approval based on tumor response rate and durability of response; continued approval is contingent upon results in confirmatory trials. Pembrolizumab has received orphan drug designation for the treatment of gastric cancer, including gastroesophageal junction adenocarcinoma and multiple myeloma.

Pembrolizumab is a human monoclonal antibody that binds to the programmed death receptor (PD-1) on T-cells to block the interaction with PD-ligands, PD-L1 and PD-L2, on the tumor cell. The interaction of PD-1 with these ligands contributes to inhibition of active T-cell immune surveillance of tumors. Upregulation of PD-L1 occurs in some tumors and can further contribute to decreased immune response. Through binding of PD-1, pembrolizumab prevents inhibition of the anti-tumor immune response.

National Comprehensive Cancer Network (NCCN) Guidelines for Melanoma recommend pembrolizumab for treatment of metastatic or unresectable melanoma as first-line therapy and as second-line or subsequent therapy in patients with a ECOG performance status of 0-2 who have disease progression if not previously used. NCCN guidelines also recommend pembrolizumab for the treatment of Non-small cell lung cancer, Classical Hodgkin Lymphoma, Head and Neck cancer, Merkel Cell carcinoma, colon and rectal cancer,.

POSITION STATEMENT:

I. Initiation of pembrolizumab (Keytruda) meets the definition of medical necessity for members diagnosed with ANY of the following conditions when ALL of the following criteria are met:

1. Melanoma

a. Member’s disease is unresectable or metastatic

b. Member meets one of the following:

i. Pembrolizumab is used as first-line therapy

ii. Pembrolizumab is used as second-line or subsequent therapy for disease progression if not previously used AND member’s ECOG performance status is 0-2

iii. Pembrolizumab is used as reinduction therapy and ALL of the following:

1. Members disease relapsed or progressed greater than 3 months after initial clinical response or stable disease with previous pembrolizumab treatment

2. Member does not have any remaining toxicity from previous pembrolizumab treatment

3. Member’s ECOG performance status is 0-2

c. Pembrolizumab will be used as monotherapy

d. Dose does not exceed 2 mg/kg every 3 weeks

2. Non-small Cell Lung Cancer (NSCLC)

a. Member’s disease is classified as ONE of the following:

a. Metastatic

b. Mediastinal lymph node recurrence and member has received prior radiation therapy

b. Member has the presence of positive PD-L1 expression as detected by an FDA-approved test and ONE of the following:

i. High PD-L1 expression with TPS > 50% and ONE of the following:

i. Pembrolizumab is used as first-line therapy if EGFR, ALK, and ROS1 are negative or unknown

ii. Pembrolizumab is used as subsequent therapy after disease progression on one of the following:

1. Targeted therapy for EGFR mutation (e.g., erlotinib, afatinib, gefitinib, osimertinib)

2. Targeted therapy for ALK rearrangements (e.g., crizotinib, ceritinib, alectinib)

3. Targeted therapy for ROS1 rearrangements (e.g., crizotinib)

ii. PD-L1 expression with TPS >1% and ALL of the following:

i. Member’s ECOG performance status is 0-2

ii. Pembrolizumab is used as subsequent therapy if not previously used after disease progression on initial chemotherapy

c. The member has not previously received a checkpoint inhibitor (e.g., nivolumab, pembrolizumab, or atezolizumab)

d. Pembrolizumab will be used as monotherapy

e. Dose does not exceed 200 mg every 3 weeks

3. Classical Hodgkin’s Lymphoma (CHL)

a. ONE of the following:

i. For relapsed or refractory disease in members 18 years of age or older

ii. For palliative therapy in members greater than 60 years of age

b. Pembrolizumab will be used as monotherapy

c. Dose does not exceed 200 mg every 3 weeks

4. Squamous cell carcinoma of the Head and Neck (SCCHN)

a. Member’s disease is recurrent, unresectable, or metastatic

b. Member’s disease progressed on or after platinum-based therapy (e.g., cisplatin or carboplatin)

c. Member’s ECOG performance status is 0-3

d. Pembrolizumab will be used as monotherapy

e. Dose does not exceed 200 mg every 3 weeks

5. Merkel Cell Carcinoma

a. Member’s disease is recurrent or metastatic

b. Pembrolizumab will be used as monotherapy

c. Dose does not exceed 2 mg/kg every 3 weeks

6. Colon or Rectal cancer

a. Member has metastatic or unresectable advanced disease

b. Tumor is classified as microsatellite instability-high [MSI-H] or mismatch repair deficient [dMMR]

c. The member has not previously received pembrolizumab or nivolumab therapy

d. ONE of the following

i. As subsequent therapy following disease progression with oxaliplatin-, irinotecan- or fluoropyrimidine-based therapy

ii. Initial therapy in members who are not candidates for more intensive therapy

iii. Following adjuvant FOLFOX or CapeOX if received within the previous year

e. Pembrolizumab will be used as monotherapy

f. Dose does not exceed 2 mg/kg every 3 weeks

Duration of approval: 6 months

II. Pembrolizumab (Keytruda) meets the definition of medical necessity when used for the following designated Orphan Drug indications (http://www.fda.gov/orphan/designat/list.htm) when used as a single agent and the dose does not exceed the maximum FDA-approved dosing:

1. Treatment of gastric cancer, including gastroesophageal junction adenocarcinoma

2. Treatment of multiple myeloma

Duration of approval: 6 months

III. Continuation of pembrolizumab (Keytruda) meets the definition of medical necessity for melanoma, NSCLC, Classical Hodgkin’s Lymphoma, squamous cell carcinoma of the head and neck, Merkel cell carcinoma, multiple myeloma, gastric cancer (including gastroesophageal junction adenocarcinoma), and colon or rectal cancer for members meeting the following criteria:

1. The member has been previously approved by Florida Blue or another health plan in the past 2 years, OR the member has previously met all indication-specific criteria for coverage

2. Member’s disease has not progressed during treatment with pembrolizumab

3. Pembrolizumab will be used as monotherapy

4. The dose does not exceed the following based on indication:

a. Melanoma, Merkel cell carcinoma, colon or rectal cancer: 2 mg/kg every 3 weeks

b. Classical Hodgkin’s Lymphoma, NSCLC, Squamous cell carcinoma of the Head and Neck: 200 mg every 3 weeks

c. Gastric cancer and multiple myeloma: does not exceed maximum FDA-approved dosing

Duration of approval: 6 months

DOSAGE/ADMINISTRATION:

THIS INFORMATION IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND SHOULD NOT BE USED AS A SOURCE FOR MAKING PRESCRIBING OR OTHER MEDICAL DETERMINATIONS. PROVIDERS SHOULD REFER TO THE MANUFACTURER’S FULL PRESCRIBING INFORMATION FOR DOSAGE GUIDELINES AND OTHER INFORMATION RELATED TO THIS MEDICATION BEFORE MAKING ANY CLINICAL DECISIONS REGARDING ITS USAGE.

FDA-approved

• Melanoma: 2 mg/kg IV over 30 minutes every three weeks. Continue treatment until disease progression or unacceptable toxicity occurs.

Non-Small Cell Lung Cancer: 200 mg IV over 30 minutes every 3 weeks. Select patients for treatment based on the presence of positive PD-L1 expression. Continue treatment until disease progression, unacceptable toxicity, or up to 24 months in patients without disease progression.

• Squamous cell carcinoma of the Head and Neck: 200 mg IV over 30 minutes every 3 weeks. Continue treatment until disease progression, unacceptable toxicity, or up to 24 months in patients without disease progression.

Dose Adjustments

• Withhold pembrolizumab for any of the following (Grades per Common Terminology Criteria for Adverse Events)::

o Grade 2 pneumonitis

o Grade 2 or 3 colitis

o Grade 3 or 4 endocrinopathies

o Grade 2 or 3 hypophysitis

o Grade 3 hyperthyroidism

o Grade 2 nephritis

o Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) greater than 3 and up to 5 times the upper limit of normal (ULN) or total bilirubin greater than 1.5 and up to 3 times the ULN

o Any other severe Grade 3 treatment-related adverse reaction

• Resume pembrolizumab in patients whose adverse reactions recover to Grade 0-1.

• Permanently discontinue pembrolizumab for any of the following:

o Any life-threatening adverse reaction (excluding endocrinopathies controlled with hormone replacement therapy)

o Grade 3 or 4 pneumonitis or recurrent pneumonitis of Grade 2 severity

o Grade 3 or 4 hypophysitis

o Grade 3 or 4 hyperthyroidism

o Grade 3 or 4 nephritis

o AST or ALT greater than 5 times the ULN or total bilirubin greater than 3 times the ULN (for patients with liver metastasis, see prescribing information)

o Grade 3 or 4 infusion-related reactions

o Inability to reduce corticosteroid dose to 10 mg or less of prednisone or equivalent per day within 12 weeks

o Persistent Grade 2 or 3 adverse reactions (excluding endocrinopathies controlled with hormone replacement therapy) that do not recover to Grade 0-1 within 12 weeks after the last dose of pembrolizumab

o Any severe or Grade 3 treatment-related adverse reaction that recurs

Drug Availability

• 50 mg, lyophilized powder in single-use vial for reconstitution

• 100 mg/4 mL (25 mg/mL) solution in a single-use vial

PRECAUTIONS:

Boxed Warning

None

Contraindications

None

Precautions/Warnings

• Immune-mediated adverse reactions: administer corticosteroids based on the severity of the reaction. See prescribing information for dose modifications and monitoring recommendations for immune-mediated reactions including: pneumonitis, colitis, hepatitis, endocrinopathies (hypophysitis, thyroid disorders, type 1 diabetes mellitus) and nephritis.

• Infusion-related reactions: stop infusion and permanently discontinue for severe or life-threatening reactions.

• Embryo-fetal toxicity: May cause fetal harm.

BILLING/CODING INFORMATION:

The following codes may be used to describe:

HCPCS Coding

J9271

Injection, pembrolizumab, 1 mg

ICD-10 Diagnoses Codes That Support Medical Necessity:

C00.0 – C08.9

Malignant neoplasm of lip, base of tongue, of other and unspecified parts of tongue, gum, floor of mouth, palate, of other and unspecified parts of mouth, parotid and salivary gland.

C09.0 – C10.9

Malignant neoplasm of tonsil and oropharynx

C11.0 – C11.9

Malignant neoplasm of nasopharynx

C12.0 – C14.8

Malignant neoplasm of piriform sinus, hypopharynx and other and ill-defined sites in the lip, oral cavity and pharynx.

C16.0 – C16.9

Malignant neoplasm of stomach

C17.0 – C17.9

Malignant neoplasm of small intestine

C18.0 – C18.9

Malignant neoplasm of colon

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.8

Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C30.0

Malignant neoplasm of nasal cavity

C31.0 – C31.9

Malignant neoplasm of accessory sinuses

C32.0 – C32.9

Malignant neoplasm of larynx

C33

Malignant neoplasm of trachea

C34.00 – C34.02

Malignant neoplasm of unspecified main bronchus

C34.10 – C34.12

Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.2

Malignant neoplasm of middle lobe, unspecified bronchus or lung

C34.30 – C34.32

Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.80 – C34.82

Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.90 – C34.92

Malignant neoplasm of unspecified part of unspecified bronchus or lung

C43.0

Malignant melanoma of lip

C43.10

Malignant melanoma of unspecified eyelid, including canthus

C43.11

Malignant melanoma of right eyelid, including canthus

C43.12

Malignant melanoma of left 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

C4A.0 – C4A.9

Merkel cell carcinoma, unspecified

C44.00

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

C69.90

Malignant neoplasm of unspecified site of unspecified eye

C69.91

Malignant neoplasm of unspecified site of right eye

C69.92

Malignant neoplasm of unspecified site of left eye

C7B.1

Secondary Merkel cell carcinoma

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 – C78.89

Secondary malignant neoplasm of respiratory and digestive organs

C79.31

Secondary malignant neoplasm of brain

C80.0

Disseminated malignant neoplasm, unspecified

C80.1

Malignant (primary) neoplasm, unspecified

C81.10 – C81.99

Hodgkin Lymphoma

C90.00 – C90.02

Multiple myeloma

D37.01

Neoplasm of uncertain behavior of lip

D37.02

Neoplasm of uncertain behavior of tongue

D37.04

Neoplasm of uncertain behavior of the minor salivary glands

D37.05

Neoplasm of uncertain behavior of pharynx

D37.09

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

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

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Part D: BCBSF has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline.

Medicare Advantage: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline revised date.

DEFINITIONS:

ALK gene rearrangements – The anaplastic lymphoma kinase (ALK) fusion oncogene is a predictive biomarker that has been identified in a subset of patients with NSCLC. Presence of the ALK arrangement is predictive of treatment benefit with ALK targeted therapies.

EGFR mutation – The presence of the epithelial growth factor receptor (EGFR) mutation (exon 19 deletion or exon 21 L858R mutation) is predictive of treatment benefit from EGFR tyrosine kinase inhibitor therapy

PD-L1 – Cytotoxic T-cell inhibition occurs when binding of the programmed death 1 (PD-1) receptor to one of its ligands: ligand 1 (PD-L1) or 2 (PD-L2). Upregulation of PD-L1 occurs in some tumors and can inhibit active T-cell surveillance of tumors. Presence of the PD-L1 biomarker in tumor cells may be predictive of treatment benefit with PD-1 inhibitors.

RELATED GUIDELINES:

Carboplatin (Paraplatin®) IV, 09-J0000-93
Dabrafenib (Tafinlar®) Capsules, 09-J2000-00

Ipilimumab (Yervoy™) IV, 09-J1000-34

Trametinib (Mekinist™) Tablets, 09-J1000-99

Vemurafenib (Zelboraf™), 09-J1000-40

OTHER:

Table 1: Eastern Cooperative Oncology Group (ECOG) Performance Status

Grade

Description

0

Fully active, able to carry on all pre-disease performance without restriction

1

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2

Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours

3

Capable of only limited self-care, confined to bed or chair more than 50% of waking hours

4

Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

5

Dead

Table 2: Common Terminology Criteria for Adverse Events v4.0 (CTCAE)

Grade

Description

1

Mild; asymptomatic or mild symptoms; clinical diagnostic observations only; intervention not indicated

2

Moderate; minimal, local or noninvasive intervention indicated; limited age-appropriate instrumental activities of daily living

3

Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care activities of daily living

4

Life-threatening consequences; urgent intervention indicated

5

Death related to adverse event

REFERENCES:

  1. AHFS Drug Information. Bethesda (MD): American Society of Health-System Pharmacists, Inc; 2016 [cited 2016 Aug 25]. In: STAT!Ref Online Electronic Medical Library [Internet]. Available from: http://online.statref.com/.
  2. Clinical Pharmacology [Internet]. Tampa (FL): Gold Standard, Inc.; 2016 [cited 2016 Aug 25]. Available from: http://www.clinicalpharmacology.com/.
  3. ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine; 2000 Feb 29 - [cited 2015 Sep 15]. Available from: http://clinicaltrials.gov/.
  4. DRUGDEX® System [Internet]. Greenwood Village (CO): Thomson Micromedex; Updated periodically [cited 2016 Aug 25]. Available from: http://www.thomsonhc.com/.
  5. Keytruda (pembrolizumab) injection [package insert]. Merck Sharp and Dohme Corp. Whitehouse Station, NJ. October 2016.
  6. National Cancer Institute. Common Terminology Criteria for Adverse Events. Available at: http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf. Accessed 9/24/15.
  7. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 1.2017. Colon cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf. Accessed 12/21/16.
  8. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 2.2016. Head and Neck Cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf. Accessed 10/11/16.
  9. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 3.2016. Hodgkin Lymphoma. Available at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf. Accessed 08/30/16.
  10. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 1.2017. Melanoma. Available at http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf. Accessed 03/06/17.
  11. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 1.2017. Merkel Cell Carcinoma. Available at http://www.nccn.org/professionals/physician_gls/PDF/mcc.pdf. Accessed 10/10/16.
  12. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 2.2017. Non-small cell lung cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf. Accessed 11/4/16.
  13. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version 1.2017. Rectal cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf. Accessed 12/21/16.
  14. National Comprehensive Cancer Network (NCCN). Drugs & Biologics Compendium [Internet]. Fort Washington (PA): National Comprehensive Cancer Network; 2017 [cited 2017 Mar 6]. Available from: http://www.nccn.org/professionals/drug_compendium/content/contents.asp/.
  15. Orphan Drug Designations and Approval [Internet]. Silver Spring (MD): US Food and Drug Administration; 2016 [2016 Aug25]. Available from: http://www.accessdata.fda.gov/scripts/opdlisting/oopd/index.cfm/.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 01/11/17.

GUIDELINE UPDATE INFORMATION:

11/15/14

New Medical Coverage Guideline.

06/15/15

Revision to guidelines; consisting of description and position statement and references

07/15/15

Revision to guidelines; updated HCPCS codes

08/15/15

Revision to guidelines; consisting of position statement.

11/15/15

Revision to guideline; consisting of updating position statement, dosing/administration, warnings/precautions, definitions, coding, and references

12/15/15

Revision to guideline; consisting of updating position statement, description and references.

01/01/16

Annual HCPCS coding update: added code J9271 and deleted codes C9027 and J9999.

6/15/16

Revision to guideline; consisting of updating position statement, description, coding and references.

7/15/16

ICD-10 coding update.

8/15/16

Revision to guideline; consisting of updating position statement and references.

9/15/16

Revision to guideline; consisting of updating description, position statement, dosing, warnings, coding and references.

10/15/16

Revision to guideline; consisting of updating position statement and references.

11/15/16

Revision to guideline; consisting of updating position statement, coding, and references.

12/15/16

Revision to guideline; consisting of updating position statement, description, dosing, coding and references.

02/15/17

Review and revision to guideline; consisting of updating position statement, description, coding and references.

04/15/17

Revision to guideline; consisting of updating position statement and references.

Date Printed: June 26, 2017: 01:23 AM