Anthem Blue Cross California Commercial Clinical Policy

Anthem Blue Cross California Akynzeo (fosnetupitant and palonosetron) for injection Form

Effective Date

12/18/2023

Last Reviewed

11/17/2023

Original Document

  Reference



Overview

Clinical Criteria

Overview

Coding

Document history

References

This document addresses the use of Akynzeo (fosnetupitant and palonosetron) for injection. Akynzeo is a combination of palonosetron, a serotonin 3 (5-HT 3) receptor antagonist, and fosnetupitant, a substance P/neurokinin-1 (NK-1) receptor antagonist. Palonosetron prevents nausea and vomiting during the acute phase, and fosnetupitant prevents nausea and vomiting during both the acute and delayed phase after cancer chemotherapy.

Akynzeo for injection has not been studied for the prevention of nausea and vomiting associated with anthracycline plus cyclophosphamide chemotherapy.

Clinical Criteria

When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), the following criteria will be used to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

Akynzeo (fosnetupitant and palonosetron) for injection

Requests for Akynzeo (fosnetupitant and palonosetron) for injection may be approved if the following criteria are met:

  • I.
  • II.
  • III.
  • Individual is 18 years of age or older; AND
  • Individual is using for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly or moderately emetogenic cancer chemotherapy (NCCN 1, Label); AND
  • Individual is using in combination with dexamethasone.

Akynzeo (fosnetupitant and palonosetron) for injection may not be approved when the above criteria are not met and for all other indications.

Coding

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.

HCPCS

J1454

ICD-10 Diagnosis

Injection, fosnetupitant 235 mg and palonosetron 0.25 mg [Akynzeo]

R11.0-R11.2

Nausea and vomiting

C00.0-C96.9

Malignant neoplasms

D00.00-D09.9

In situ neoplasms

Z51.11

Encounter for antineoplastic chemotherapy

Z85.00-Z85.9

Personal history of malignant neoplasm

  1. Document History

Revised: 11/17/2023