Aetna considers Erwinaze (asparaginase Erwinia chrysanthemi) medically necessary for persons with acute lymphoblastic leukemia who are hypersensitive to Elspar (aspariginase Escherichia coli) or Onscapar (pegaspargase).
Continued use beyond three months is considered medically necessary for persons with no evidence of disease progression relative to pre-treatment state.
Aetna considers Erwinaze experimental and investigational for persons with any of the following contraindications:
Persons with a history of serious pancreatitis with prior L-asparaginase therapy
Persons with a history of thrombosis with prior L-asparaginase therapy
Persons who are hypersensitive to Erwinaze.
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
96401
HCPCS codes covered if selection criteria are met:
J9019
Injection, asparaginase, (Erwinaze), 1,000 iu
Other HCPCS codes related to the CPB:
J9020
Injection, asparaginase, not otherwise specified, 10,000 units [Elspar]
J9266
Injection, pegaspargase, per single dose vial [Oncaspar]
ICD-9 codes covered if selection criteria are met:
204.00 - 204.02
Acute lymphoid leukemia [lymphoblastic]
ICD-9 codes contraindicated for this CPB:
434.00 - 434.01
Cerebral thrombosis
444.21 - 444.22
Embolism and thrombosis of arteries of the extremities
452
Portal vein thrombosis
453.0 - 453.9
Other venous embolism and thrombosis
577.0 - 577.1
Pancreatitis
995.27
Other venous embolism and thrombosis
The above policy is based on the following references:
NCCN Clinical Practice Guidelines: Acute Lymphoblastic Leukemia. V 1.2012.
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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