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Clinical Policy Bulletin:
Palifermin (Kepivance)
Number: 0851


Policy

Aetna considers palifermin (Kepivance) medically necessary for members with the diagnosis of hematologic malignancies receiving myelotoxic therapy requiring hematopoietic stem cell support who develop oral mucositis of WHO grade 3 or 4 (see Table 4 in appendix), after failure of standard of care in the prior treatment regimen as follows:

  1. Routine oral hygine care (see Table 1 in appendix); and
  2. Use of 3 agents, including morphine PCA, from the folloing classes: topical anesthetics, mucosal coating agents, and analgesics (see Table 2 in appendix).

Aetna considers palifermin experimental and investigational for gastrointestinal mucositis and all other indications. 



Background

Effective oral hygiene, appropriate analgesia, oral cryotherapy, infection management and parenteral nutrition are considered to be standard of care for oral mucositis.

Appendix

Table 1: Routine Oral Hygiene Care

  • Toothbrushing. [Note: Electric and ultrasonic toothbrushes are acceptable if the patient is capable of using them without causing trauma.]

  • Soft nylon-bristled brush (2-3 rows).

    • Brush 2 to 3 times daily with Bass sulcular scrub method.
    • Rinse frequently.
    • Foam toothbrushes:

      • Use only when use of a regular toothbrush is not feasible.
      • Use with antimicrobial rinses when possible.
      • Brush teeth and mucosal surfaces 2 to 3 times a day.
      • Rinse frequently.

  • Dentifrice:

    • Patient preference as tolerated.
    • Fluoride recommended.
    • Use 0.9% saline or water if toothpaste causes irritation.

  • Flossing:

    • Once daily.
    • Atraumatic technique with modifications as needed.

  • Bland Rinses:

    • Varieties:

      • 0.9% saline.
      • Sodium bicarbonate solution.
      • 0.9% saline plus sodium bicarbonate solution.

    • Use 8 to 12 oz of rinse, hold and expectorate; repeat every 2 to 4 hours or as needed for pain.

  • Fluoride:

    • 1.1% neutral sodium fluoride gel.
    • 0.4% stannous fluoride gel.
    • Brush on gel for 2 to 3 minutes.
    • Expectorate and rinse mouth gently.
    • Apply once a day.

  • Topical antimicrobial rinses:

    • 0.12% to 0.2% chlorhexidine oral rinse.
    • Povidone iodine oral rinse.
    • Rinse, hold 1 to 2 minutes, expectorate.
    • Repeat 2 to 4 times a day depending on severity of periodontal disease.  

Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-Dose Cancer Therapy

  • Minimize denture use during first 3 to 4 weeks posttransplant.

    • Wear dentures only when eating.
    • Discontinue use at all other times.

  • Clean twice a day with a soft brush and rinse well.
  • Soak in antimicrobial solutions when not being worn.
  • Perform routine oral mucosal care procedures 3 to 4 times a day with the oral appliances out of the mouth.
  • Leave appliances out of mouth when sleeping and during periods of significant mouth soreness.
  • Dentures may be used to hold medications needed for oral care (e.g., antifungals).
  • Discontinue use of removable
  • Discontinue use of removable appliances until oral mucositis has healed.

Remove orthodontic appliances (e.g., brackets, wires, retainers) prior to conditioning.

Table 2: Mucositis Management

 

Table 3: Summary of Clinical Practice Guidelines for Care of Patients with Oral Mucositis

Basic Oral Care and Good Clinical Practices

  1. The panel suggests multidisciplinary development and evaluation of oral care protocols, and patient and staff education in the use of such protocols to reduce the severity of oral mucositis from chemotherapy and/or radiation therapy (Level III evidence, grade B suggestion). As part of the protocols, the panel suggests the use of a soft toothbrush that is replaced on a regular basis. Elements of good clinical practice should include the use of validated tools to regularly assess oral pain and oral cavity health. The inclusion of dental professionals is vital throughout the treatment and follow-up phases.
  2. The panel recommends patient-controlled analgesia with morphine as the treatment of choice for oral mucositis pain in patients undergoing hematopoietic stem cell transplantation (HSCT) (Level 1 evidence, grade A recommendation). Regular oral pain assessment using validated instruments for self-reporting is essential.

Radiotherapy: Prevention

  1. The panel recommends the use of midline radiation blocks and 3-dimensional radiation treatment to reduce mucosal injury. (Level 2 evidence, grade B recommendation)
  2. The panel recommends benzydamine for prevention of radiation-induced mucositis in patients with head and neck cancer receiving moderate-dose radiation therapy. (Level I evidence, grade A recommendation)
  3. The panel recommends that chlorhexidine not be used to prevent oral mucositis in patients with solid tumors of the head and neck who are undergoing radiotherapy. (Level II evidence, grade B recommendation)
  4. The panel recommends that antimicrobial lozenges not be used for the prevention of radiation-induced oral mucositis. (Level II evidence, grade B recommendation)

Radiotherapy: Treatment

  1. The panel recommends that sucralfate not be used for the treatment of radiation-induced oral mucositis. (Level II evidence, grade A recommendation)

Standard-Dose Chemotherapy Prevention

  1. The panel recommends that patients receiving bolus 5-fluorouracil (5-FU) chemotherapy undergo 30 minutes of oral cryotherapy to prevent oral mucositis. (Level II evidence, grade A recommendation)
  2. The panel suggests the use of 20 to 30 minutes of oral cryotherapy to decrease mucositis in patients treated with bolus doses of edatrexate. (Level IV evidence, grade B suggestion)
  3. The panel recommends that acyclovir and its analogues not be used routinely to prevent mucositis. (Level II evidence, grade B recommendation)

Standard-Dose Chemotherapy: Treatment

  1. The panel suggests that chlorhexidine not be used to treat established oral mucositis. (Level III evidence, grade C recommendation)

High-Dose Chemotherapy With or Without Total Body Irradiation Plus HCST: Prevention

  1. In patients with hematologic malignancies who are receiving high-dose chemotherapy and total body irradiation with autologous stem cell transplantation, the panel recommends the use of keratinocyte growth factor-1 (palifermin) in a dose of 60 micrograms/kg per day for 3 days prior to conditioning treatment and for 3 days posttransplantation for the prevention of oral mucositis. (Level 1 evidence, grade A recommendation)
  2. The panel suggests the use of cryotherapy to prevent oral mucositis in patients receiving high-dose melphalan. (Level II evidence, grade A recommendation)
  3. The panel does not recommend the use of pentoxifylline to prevent mucositis in patients undergoing HSCT. (Level II evidence, grade B recommendation) 
  4. The panel suggests that granulocyte macrophage colony-stimulating factor (GM-CSF) mouthwashes not be used for the prevention of oral mucositis in patients undergoing HSCT. (Level II evidence, grade C recommendation)
  5. The panel suggests the use of low-level laser therapy (LLLT) to reduce the incidence of oral mucositis and its associated pain in patients receiving high-dose chemotherapy or chemoradiotherapy before HSCT if the treatment center is able to support the necessary technology and training, because LLLT requires expensive equipment and specialized training. Because of interoperator variability, clinical trials are difficult to conduct, and their results are difficult to compare; nevertheless, the panel is encouraged by the accumulating evidence in support of LLLT. (Level II evidence, grade B recommendation)

Key: HSCT: hematopoietic stem cell transplantation; 5-FU: 5-fluorouracil; TBI: total-body irradiation; LLLT: low-level laser therapy.

Table 4: WHO Classification of Oral Mucositis

Grade 0                  No oral mucositis

Grade 1                  Soreness +/- erythema

Grade 2                  Erythema and ulcers

Grade 3                  Extensive erythema, ulcers and inability to swallow solid food

Grade 4                  Mucositis that prevents any form of alimentation, including swallowing liquids

 

Bland Rinses:

  • 0.9% saline solution
  • Sodium bicarbonate solution
  • 0.9% saline/sodium bicarbonate solution. 

Topical anesthetics:

  • Lidocaine: viscous, ointments, sprays.
  • Benzocaine: sprays, gels.
  • 0.5% or 1.0% dyclonine hydrochloride (HCl).
  • Diphenhydramine solution.

Mucosal coating agents:

  • Amphojel.
  • Kaopectate.
  • Hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin).
  • Cyanoacrylate mucoadherent film.

Analgesics:

  • Benzydamine HCl topical rinse. (not approved in the United States)
  • Opioid drugs: oral, intravenous (IV) (e.g., bolus, continuous infusion, patient-controlled analgesia [PCA]), patches, transmucosal.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
38240 Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor
38241     autologous transplantation
38242     HPC boost
HCPCS codes covered if selection criteria are met:
J2425 Injection, palifermin, 50 micrograms
ICD-9 codes covered if selection criteria are met:
528.01 Mucositis (ulcerative) due to antineoplastic therapy


The above policy is based on the following references:
  1. Kepivance Prescribing Information. Amgen, Inc. January 2010.
  2. http://www.guideline.gov/summary/summary.aspx?doc_id=12094
  3. National Cancer Institute, Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®), webpage accessed 3/15/10. (http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional)
  4. Spielberger R, Stiff P, Bensinger W, et al. Palifermin for oral mucositis after intensive therapy for hematologic cancers. New England Journal of Medicine. 2004; 351(25): 2590-2598.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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