Anthem Blue Cross California Selected Injectable 5HT3 Antiemetic Agents Form

Overview

This document addresses the use of injectable neurokinin 1 (NK-1) receptor antagonist injections: Emend, Focinvez, and Cinvanti. Oral NK-1 receptor antagonists are not addressed in this document. Neurokinin-1 receptors, which are in the vomiting and vestibular centers of the brain, are thought to be involved in emesis. NK1 receptors are associated with delayed emesis via a central pathway. Because no final common pathway for emesis has been identified, no single agent is expected to provide complete protection from emesis due to chemotherapy.

Emend, Focinvez, and Cinvanti are recommended for use in the treatment of acute and delayed nausea and vomiting, in combination with serotonin (5-HT3) receptor antagonists and a corticosteroid (usually dexamethasone). Emend, Focinvez, and Cinvanti are recommended for use for highly emetogenic and moderately emetogenic chemotherapy (NCCN 2022).

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.

fosaprepitant (Emend, Focinvez) injection

Requests for fosaprepitant (Emend, Focinvez) Injectable may be approved if the following criteria are met:

1. Individual is using to prevent acute and delayed nausea and vomiting associated with initial and repeat courses of highly and moderately emetogenic cancer chemotherapy; AND
2. Individual is using in combination with other antiemetic agents (serotonin receptor antagonist [5HT-3] and dexamethasone) (NCCN 1, Label).

fosaprepitant (Emend, Focinvez) injection may not be approved for the following:

1. All other indications not included above; OR
2. Treatment of established nausea and vomiting; OR
3. Concomitant use with pimozide (Orap).

Cinvanti (aprepitant) injection

Requests for Cinvanti (aprepitant) injection may be approved if the following criteria are met:

1. Individual is using to prevent acute and delayed nausea and vomiting associated with initial and repeat courses of highly or moderately emetogenic cancer chemotherapy; AND
2. Individual is using in combination with other antiemetic agents (serotonin receptor antagonist [5HT-3] and dexamethasone) (NCCN 1, Label).

Cinvanti (aprepitant) injection may not be approved for the following:

1. All other indications not included above; OR
2. Treatment of established nausea and vomiting; OR
3. Concomitant use with pimozide (Orap).

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

• J1453 Injection, fosaprepitant, 1 mg [Emend]
• J1456 Injection, fosaprepitant, 1 mg (Teva)
• J0185 Injection, aprepitant, 130 mg/18 mL [Cinvanti]
• C9145 Injection, aprepitant, 1 mg [Aponvie]
• J3490 Unclassified drugs (when specified as [Focinvez] (fosaprepitant))

ICD-10 Diagnosis

• C00.0-C96.9 Malignant neoplasms
• R11.0-R11.2 Nausea and vomiting
• Z51.11-Z51.12 Encounter for antineoplastic chemotherapy
• T45.1X5A-T45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs
• T45.95XA Adverse effect of unspecified primarily systemic and hematological agent, initial encounter
• T50.905A Adverse effect of unspecified drugs, medicaments and biological substances

Document History

Revised: 11/17/2023