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Clinical Policy Bulletin:
Oprelvekin (Neumega)
Number: 0855


Policy

Aetna considers oprelvekin (Neumega) medically necessary for prevention of thrombocytopenia in persons who are receiving myelosuppressive therapy for nonmyeloid malignancies who are at high risk of severe thrombocytopenia (i.e., platelet count less than 50,000 or previous thromobytopenia with prior chemotherapy).. Aetna considers oprelvekin experimental and investigational for all other indications.



 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
HCPCS codes covered if selection criteria are met :
J2355 Injection, oprelvekin, 5 mg
ICD-9 codes covered if selection criteria are met:
140.0 - 204.92, 206.00 - 234.9 Malignant neoplasms [excluding non- myeloid malignancies]
Other ICD-9 codes related to the CPB:
287.5 Thrombocytopenia, unspecified


The above policy is based on the following references:
  1.  Neumega [package insert]. Philadelphia, PA:Wyeth Pharmaceuticals, Inc.; January 2011.


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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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