This policy is based in part on antiemetic practice guidelines from the National Comprehensive Cancer Network (NCCN) (2008; updated 2012) and the American College of Obstetrics and Gynecology (ACOG) practice guidelines on nausea and vomiting of pregnancy (2004).
Aetna considers palonosetron (Aloxi) or fosaprepitant dimeglumine (Emend) antiemetic therapy medically necessary for either of the following indications: (i) the prevention of acute nausea or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy, including high-dose cisplatin; or (ii) for treatment of chemotherapy-induced nausea or vomiting from low or minimally emetogenic cancer chemotherapy in persons who have an inadequate response or contraindication to intravenous granisetron (Kytril) or ondansetron (Zofran) at the Food and Drug Administration (FDA) recommended dose (see table in Appendix).
Aetna considers granisetron (Kytril) and ondansetron (Zofran) antiemetic intravenous therapy medically necessary for the following indications: (i) prevention of acute and delayed nausea and/or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy including high-dose displatin; and (ii) for treatment of chemotherapy-induced nausea and/or vomiting of low or minimally emetogenic cancer chemotherapy in persons who have an inadequate response or contraindication to oral granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose (see table in Appendix).
Aetna considers intravenous dolasetron (Anzemet) experimental and investigational for prevention of nausea or vomiting from cancer chemotherapy.
Aetna considers dolasetron mesylate (Anzemet), medically necessary for the prevention of radiation-induced nausea or vomiting secondary to total body irradiation (TBI) when intravenous antiemetic therapy with granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers granisetron (Kytril) or ondansetron (Zofran) medically necessary for the prevention of radiation-induced nausea and/or vomiting secondary to TBI when oral granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers intravenous palonosetron (Aloxi) and fosaprepitant dimeglumine (Emend) experimental and investigational for the prevention of radiation-induced nausea and vomiting because there is insufficient evidence of their effectiveness for this indication.
Aetna considers intravenous palonosetron (Aloxi), dolasetron mesylate (Anzemet) or fosaprepitant dimeglumine (Emend) medically necessary for the prevention or treatment of post-operative nausea or vomiting when intravenous granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers intravenous granisetron (Kytril) or ondansetron (Zofran) medically necessary for the prevention or treatment of post-operative nausea or vomiting when oral granisetron (Kytril) or ondansetron (Zofran) has failed or is contraindicated.
Note: As with other antiemetics, routine prophylaxis is not recommended for individuals in whom there is little expectation that nausea and/or vomiting will occur post-operatively.
Aetna considers intravenous granisetron (Kytril) or ondansetron (Zofran) antiemetic intravenous therapy medically necessary for severe, intractable, persistent nausea or vomiting during pregnancy when clinical signs of dehydration are present or nausea and vomiting have persisted for more than 3 weeks and all of the following conditions are met:
Conservative treatment has failed (e.g., dietary changes, ginger, multi-vitamin, vitamin B6 (pyridoxine) with or without doxylamine (Unisom)); and
Oral, sublingual, or rectal antiemetics have failed or are contraindicated including 2 or more of the following:
Dimenhydrinate (Dramamine); and
Ondansetron (Zofran) or granisetron (Kytril); and
Promethazine (Phenergan); and
Trimethobenzamide (Tigan); and
Other injectable/intravenous antiemetics have failed or are contraindicated including all of the following:
Dimenhydrinate (Dramamine); and
Aetna considers intravenous palonosetron (Aloxi), dolasetron mesylate (Anzemet) or fosaprepitant dimeglumine (Emend) medically necessary for severe, intractable, persistent nausea or vomiting during pregnancy when clinical signs of dehydration are present or nausea and vomiting have persisted for more than 3 weeks and intravenous granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers 5-HT3 receptor antagonist antiemetic intravenous therapy experimental and investigational for motion-induced nausea and vomiting (motion-sickness).
Aetna considers granisetron (Kytril) or ondansetron (Zofran) antiemetic intravenous therapy medically necessary for refractory cases of nausea or vomiting for other indications (e.g., bulimia nervosa, cyclic vomiting syndrome, HIV) when oral granisetron (Kytril) or ondansetron (Zofran) has failed or is contraindicated.
Aetna considers intravenous palonosetron (Aloxi), dolasetron mesylate (Anzemet) or fosaprepitant dimeglumine (Emend) medically necessary for refractory cases of nausea or vomiting for other indications (e.g., bulimia nervosa, cyclic vomiting syndrome, HIV) when intravenous granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Note: This policy does not address the use of 5-HT3 receptor antagonists in the emergency room. Serotonin 3 receptor antagonists have been used in the management of acute toxicities (e.g., acetaminophen, theophylline).
Serotonin 3 (5-HT3) receptor antagonists [(i.e., palonosetron (Aloxi), dolasetron mesylate (Anzemet), granisetron (Kytril), and ondansetron (Zofran)] are used for the treatment and prevention of post-operative nausea and vomiting as well as nausea and vomiting caused by cancer chemotherapy, radiotherapy, and pregnancy. 5-HT3 receptor antagonists work by blocking serotonin binding at vagal afferents in the gut and in regions of the central nervous system (CNS) involved in emesis.
Antiemetic practice guidelines from the National Comprehensive Cancer Network (NCCN, 2008) recommend antiemetic regimens based upon the emetogenic potential of the chemotherapy drug as well as individual risk factors. The antiemetic regimen for highly emetogenic drugs includes aprepitant, dexamethasone, and a 5-HT3 antagonist with or without lorazepam. The antiemetic regimen for moderately emetogenic drugs includes dexamethosone and a 5-HT3 antagonist (palonosetron is preferred) with or without lorazepam; consider adding aprepitant for select patients (those receiving carboplatin, cyclophosphamide, doxorubixin, epirubicin, ifosfamide, irinotecan, or methotrexate). The antiemetic regimen for low emetogenic drugs includes the following non-5-HT3 anatgonists: dexamethasone with or without lorazepam, prochlorperazine, spansule, or metoclopramide with or without diphenhydramine. For minimal risk chemotherapy, the NCCN guidelines recommend that no routine prophylactic treatment be given.
According to NCCN, the basic strategy of any antiemetic regimen is to prevent nausea/vomiting from occurring, thus, prophylactic antiemetics should be administered before chemotherapy begins and for patients receiving high or moderate emetogenic chemotherapy, antiemetics should continue for at least 4 days. Although oral and intravenous (I.V.) antiemetics have equivalent efficacy, patients who are unable to swallow or digest tablets because of emesis, should be given I.V. antiemetics (NCCN). Breakthrough nausea/vomiting induced by high, moderate and low emetic risk chemotherapy can be very difficult to treat. Adding an additional agent from a different drug class is the general management approach recommended by NCCN as well as adjusting either the intensity or frequency of dosing. Dopamine antagonists, metoclopramide, thiethylperazine, butyrophenones (e.g., halpreridol), corticosteroids, and agents such as lorazepam may be required. Routine around-the-clock administration should be considered, rather than as needed. Also, while not likely to be effective, anecdotal evidence suggests that switching to a different 5-HT3 may be efficacious (NCCN).
Studies have demonstrated that all of the 5-HT3 antagonists are effective and have mild, infrequent side effects, although optimal antiemetic therapy requires concomitant dexamethasone or methylprednisolone, unless the patient can not tolerate corticosteroids (NCCN). According to the NCCN guidelines, dolasetron mesylate, granisetron, and ondansetron are effective in preventing acute emesis but are less effective for delayed emesis compared with palonosetron. Palonosetron is effective for preventing both delayed and acute emesis and is the preferred medication for patients undergoing moderate emetic risk chemotherapy (NCCN). In the trial data submitted to the Food and Drug Adminsitration (FDA) for licensure, palonosetron achieved equivalent or superior results compared to the control arms (ondansetron and dolasetron), especially with regard to delayed nausea. The side effect and safety profile of palonosetron has been demonstrated to be the same as dolasetron mesylate and ondansetron but it has a slightly higher tissue binding affinity for the 5-HT3 receptor and a significantly longer serum half-life than other 5-HT3 antagonists. Palonosetron is administered intravenously and is approved by the FDA as a single dose of 0.25 mg I.V. over 30 seconds on day 1, approximately 30 mins before chemotherapy. Higher doses (e.g., 0.75 mg) were studied and were no more effective than the 0.25 mg dose. Repeat dosing of palonosetron in the days following chemotherapy (e.g., day 2 to 3) or in the setting of multi-day chemotherapy regimens is not supported by the scientific literature.
In December 2010, the FDA released a special announcement that the injection form of dolasetron mesylate (Anzemet) should no longer be used to prevent nausea and vomiting associated with CINV in pediatric and adult patients. New data demonstrated that intravenous dolasetron can increase the risk of developing an abnormal heart rhythm (torsade de pointes) which can be fatal.
The Multinational Association of Supportive Care in Cancer (MASCC) International Consensus Conference (2005) classified the risk of radiotherapy-induced emesis as follows: (i) high - total body irradiation, (ii) moderate - upper abdomen, (iii) low - lower thorax, pelvis, cranium (radiosurgery) and craniospinal, (iv) minimal risk - head and neck, extremities, cranium and breast (Maranzano et al, 2005). NCCN (2006) antiemesis guidelines for the use of antiemetics in radiotherapy are based on the site of radiation and whether radiotherapy is combined with chemotherapy; when radiotherapy is combined with chemotherapy, prophylaxis is dictated by the emetogenic potential of the chemotherapy regimen. For total body irradiation, NCCN guidelines recommend pretreatment for each day of radiation treatment with either oral ondansetron or oral / I.V. granisetron. For upper abdomen radiation, NCCN guidelines recommend pretreatment for each day of radiation treatment with either oral ondansetron or oral granisetron. NCCN guidelines do not recommend primary treatment for patients receiving radiation to other sites.
Nausea and vomiting are common in pregnancy. Approximately 70 to 85 % of pregnant women experience nausea and/or vomiting. Hyperemesis gravidarum, a severe and intractable form of nausea and vomiting during pregnancy, may result in weight loss, nutritional deficiencies, and dehydration. The peak incidence occurs at 8 to 12 weeks of pregnancy, and symptoms usually resolve by week 16. The American College of Obstetrics and Gynecology (ACOG) (2004) recommend a step-wise approach to alleviating nausea and vomiting in pregnancy, beginning with prevention at the time of conception. Two studies found that women who take a multi-vitamin at the time of conception were less likely to need medical attention for vomiting. While there is little published evidence regarding the efficacy of dietary changes for prevention or treatment of nausea and vomiting of pregnancy, a small study showed that protein meals were more likely to relieve nausea and vomiting of pregnancy than carbohydrate and fatty meals. Other conservative treatments recommended by ACOG included ginger capsules and electrical stimulation or acupressure at the P6 (or Neguian) point on the inside of the wrist. Women with more complicated nausea and vomiting of pregnancy may need pharmacologic therapy. While many conventional antiemetics have been used for nausea and vomiting of pregnancy, it is important to note that no drug has been approved by the FDA for the treatment of nausea and vomiting in pregnancy since Benedictine (an antiemetic no longer available in the U.S. but still widely used in Europe).
According to ACOG guidelines, pharmacologic treatment of nausea and vomiting of pregnancy should begin with pyridoxine (vitamin B6). If there is no improvement, doxylamine (Unisom) should be added with the pyridoxine. A 70 % reduction in nausea and vomiting has been reported with this combination. Doxylamine and pyridoxine are currently available separately without a prescription in the U.S. Several studies involving more than 170,000 exposures have found this combination to be safe with regard to fetal exposure. If this is unsuccessful, adding or switching to antiemetics and antihistamines may be necessary. Medications for which there are some safety data but no conclusive evidence of efficacy include anticholinergics and metoclopramide (Reglan) (ACOG, 2004).
Evidence is limited on the safety and efficacy of ondansetron injectable for treatment of pregnancy-related nausea and vomiting. However, this medication is being prescribed as an off-label use for the treatment of nausea and vomiting of pregnancy due to its reported effectiveness in reducing chemotherapy-induced emesis (ACOG, 2004). In a limited comparative study with other antiemetics, no increased risks of major malformations were reported (Einarson et al, 2004). In a small trial of I.V. therapy in women with hyperemesis gravidarum, no increased benefit was demonstrated with ondansetron over promethazine (Sullivan et al, 1996). However, according to ACOG’s step-wise approach to managing nausea and vomiting of pregnancy, ondansetron may be tried in refractory cases as a last resort. When indicated, ACOG guidelines recommend 8 mg of ondansetron over 15 mins every 12 hrs I.V.
According to the peer-reviewed medical literature, selective 5-HT3 receptor antagonists have been proven safe and effective for the management of post-operative nausea and vomiting (Loewen et al, 2000; Kovac, 2000; Fuji, 2005).
Ondansetron for bulimia nervosa was reported to be effective in 3 small trials by one group of investigators, and may be an option after failure of traditional therapies (Fung and Ferrill, 2001). Additionally, some studies on bulimia nervosa recommend short-term use of antiemetics at the onset of a patient's treatment. Antiemetics are thought to reduce a patient's stimuli to vomit and help patients through the few weeks it takes for antidepressants to become fully effective (Moreno, 2005).
A Prodigy Clinical Practice Recommendation (SCHIN, 2006) on palliative care - nausea/vomiting/malignant bowel obstruction.stated, “[o]ndansetron, tropisetron, granisetron, and dolasetron are rarely indicated in the palliative care setting. Their use is limited to chemotherapy and radiotherapy induced nausea…[t]he role of somatostatin analogues in the relief of nausea and vomiting due to malignant bowel obstruction is not clear.”
In a single-blind, randomized controlleds tudy, Yonemura et al (2009) evaluated the non-inferiority of 1-mg to 3-mg granisetron (GRN) injection for the treatment of acute chemotherapy-induced nausea and vomiting (CINV) and assessed the tolerability of GRN given at 1-mg in Japanese cancer patients. Patients with cancer receiving highly emetogenic chemotherapy were enrolled in this study. Patients were randomly assigned to receive GRN at a single dose of 1-mg or 3-mg. The primary endpoint was the rate of complete protection from emetic events (no vomiting, no retching and no need for rescue medication) during the first 24 hrs following the initiation of chemotherapy. There were 89 patients in the 1-mg group and 90 patients in the 3-mg group. Complete protection was achieved in 70 patients (78.7 %) in the 1-mg group and 73 (81.1 %) patients in the 3-mg group. The 1-sided test did not reveal non-inferiority of either dose of GRN to the other at a 5 % significance level. The authors concluded that these findings failed to show the non-inferiority of 1-mg of GRN to 3-mg of GRN administered as a single dose. However, the rate of complete protection from nausea and vomiting was similar in the 2 groups. They stated that given the recommended dosage in the guidelines and the economic need for reduction of medical care expenses in Japan, prophylactic administration of GRN at 1-mg may be an appropriate, alternative treatment for acute CINV in cancer patients.
Results of clinical trials indicated that 5-HT3 receptor antagonists for the reduction of motion sickness have not been proven effective (Levine et al, 2000; Reid et al, 2000).
Table: Emetogenic Potential of Intravenous and Oral Antineoplastic Agents
Emetic Risk Without Prophylaxis
High-risk (greater than 90 % frequency of emesis)*
AC combination defined as either doxorubicin or epirubicin with cyclophosphamide Altretamine (oral) Carmustine > 250 mg/m2 Cisplatin ≥ 50 mg/m2 Cyclophosphamide > 1,500 mg/m2
*Proportion of patients who experience emesis in the absence of effective antiemetic prophylaxis
Note: National Comprehensive Cancer Network guidelines on antiemesis lists the emetogenic potential of additional cancer drugs; these guidelines are available at the following web address (free registration required): http://www.nccn.org/clinical.asp.
Source: NCCN Clinical Practice Guidelines in Oncology. Guidelines for Supportive Care. Antiemesis. Version 3.2008. Jenkintown, PA; NCCN; 2008. (Updated version: 1.2012; Fort Washington, PA: NCCN)
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to this CPB:
77371 - 77425
Radiation treatment delivery
96401 - 96549
HCPCS codes covered if selection criteria are met:
Injection, dolasetron mesylate, 10 mg
Injection, fosaprepitant, 1 mg
Injection, granisetron HCl, 100 mcg
Injection, ondansetron HCl, per 1 mg
Injection, palonosetron HCl, 25 mcg
HCPCS codes related to High Emetic Risk Without Prophylaxis (greater than 90% frequency of emesis):
Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg
HCPCS codes related to Minimal Emetic Risk Without Prophylaxis (< 10% frequency of emesis):
Injection, busulfan, 1 mg
Injection, dexrazoxane HCl, per 250 mg
Busulfan, oral, 2mg
Gefitinib, oral, 250 mg
Melphalan, oral, 2 mg [low-dose]
Methotrexate, oral, 2.5 mg [< 50 mg/m2]
Injection, alemtuzumab, 10 mg
Injection, asparaginase, 10,000 units
Injection, bevacizumab, 10 mg
Injection, bleomycin sulfate, 15 units
Injection, cladribine, per 1 mg
Injection, fludarabine phosphate, 50 mg
Injection, interferon alfacon-1, recombinant, 1 mcg
Injection, interferon alfa-2A, recombinant, 3 million units
Injection, interferon alfa-2B, recombinant, 1 million units
Injection, interferon alfa-N3, (human leukocyte derived), 250,000 IU
Injection, ipilimumab, 1 mg
Injection, melphalan HCI, 50 mg [oral low-dose]
Methotrexate sodium, 5 mg [< 50 mg/m2]
Methotrexate sodium, 50 mg [< 50 mg/m2]
Injection, gemtuzumab ozogamicin, 5 mg
Injection, ofatumumab, 10 mg
Injection, pertuzumab, 1 mg
Injection, rituximab, 100 mg
Injection, valrubicin, intravesical, 200 mg
Injection, vinblastine sulfate, 1 mg
Vincristine sulfate, 1 mg
Injection, vinorelbine tartrate, per 10 mg
Imatinib, 100 mg
Chlorambucil, oral, 2 mg
Hydroxyurea, oral, 500 mg
Other HCPCS codes related to this CPB:
Multiple vitamins, with or without minerals and trace elements, oral, per dose, not otherwise specified
Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump
Injection, dimenhydrinate, up to 50 mg
Injection, promethazine HCl, up to 50 mg
Injection, trimethobenzamide HCl, up to 200 mg
Injection, pyridoxine HCl, 100 mg
Q0083 - Q0085
Ondansetron 1 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at a time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
Ganisetron HCl, 1 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen
Promethazine HCl, 12.5 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen
Dolasetron mesylate, 100 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen
Ganisetron HCl, 1 mg (for circumstances falling under the Medicare statute, use Q0166)
Ondansetron, oral 4 mg (or circumstances falling under the medicare statute, use Q0162)
Dolasetron mesylate, oral, 50 mg (for circumstances falling under the Medicare statute, use Q0180)
Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and visits coded separately), per diem
Home therapy, intermittent antiemetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem [covered for high or moderate emetic risk only]
ICD-9 codes covered if selection criteria are met:
Human immunodeficiency virus [HIV] disease
Persistent vomiting [cyclical]
643.00 - 643.93
Excessive vomiting in pregnancy [when clinical signs of dehydration are present or nausea and vomiting have persisted more than 3 weeks and criteria A,B, and C are met]
787.01 - 787.03
Nausea and vomiting [when criteria are met]
Effects of radiation, unspecified [nausea or vomiting secondary to total body irradiation]
Adverse effect of antineoplastic and immunosuppressive drugs [not covered for Anzemet]
Encounter for radiotherapy [for total body radiation when oral antiemetic therapy has failed or is contraindicated]
V58.11 - V58.12
Encounter for antineoplastic chemotherapy and immunotherapy [with initial and repeat courses of moderately highly emetogenic cancer chemotherapy and for breakthrough chemotherapy induced nausea and vomiting of low emetogenic cancer chemotherapy]
ICD-9 codes not covered for indications listed in the CPB:
Other ICD-9 codes related to this CPB:
140.0 - 208.91
230.0 - 234.9
Carcinoma in situ
Hyperosmolality and/or hypernatremia
Hyposmolality and/or hyponatremia
Postgastric surgery syndromes
Digestive system complications
Other postprocedural status
The above policy is based on the following references:
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Guidelines for Supportive Care. Antiemesis. Version 1.2006. Jenkintown, PA: NCCN; January 10, 2006: 1-32. Available at: http://www.nccn.org/. Accessed March 10, 2006.
Roila F, Hesketh PJ, Herrstedt J; Antiemetic Subcommittee of the Multinational Association of Supportive Care in Cancer. Prevention of chemotherapy- and radiotherapy-induced emesis: Results of the 2004 Perugia International Antiemetic Consensus Conference. Ann Oncol. 2006;17(1):20-28.
Maranzano E, Feyer PCh, Molassiotis A, et al; Participants in the Perugia Consensus Conference 2004. Evidence-based recommendations for the use of antiemetics in radiotherapy. Radiother Oncol. 2005;76(3):227-233.
Kris MG, Hesketh PJ, Herrstedt J, et al. Consensus proposals for the prevention of acute and delayed vomiting and nausea following high-emetic-risk chemotherapy. Support Care Cancer. 2005;13(2):85-96.
Aguilar AE, Figueiras CM, Cortes-Funes H, et al. Clinical practice guidelines on antiemetics in oncology. Expert Rev Anticancer Ther. 2005;5(6):963-972.
U.S. Food and Drug Administration (FDA). Aloxi (palonosetron hydrochloride) injection prescribing information. Rockville, MD: FDA; 2005. Available at: http://www.fda.gov/cder/foi/nda/2003/21-372_Alox_Prntlbl.pdf. Accessed March 10, 2006.
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