Bendamustine is considered experimental and investigational for all other indications.
Background
Bendamustine (Treanda) is a alkylatic agent used in the treatment of chronic lymphocytic leukemia and non-Hodgkin lymphomas. Bendamustine was approved by the U.S. Food and Drug Administration in March 2008 for the treatment of chronic lymphocytic leukemia, and in October 2008, for treatment of indolent B-cell non-Hodgkin's lymphomas that have progressed during or within six months of treatment with rituximab or a rituximab-containing regimen.
Appendix
Bendamustine is considered medically necessary for the following indicaitons (based upon current guidelines from the National Comprehensive Cancer Network (NCCN, 2013)):
Classical Hodgkin Lymphoma - Second-line or salvage therapy as a single agent with or without radiation therapy prior to autologous stem cell rescue for progressive disease or for relapsed disease
Lymphocyte-predominant Hodgkin Lymphoma (LPHL) - Second-line therapy as a single agent or in combination with rituximab for symptomatic progressive or relapsed disease
Multiple myeloma - Salvage therapy on or off clinical trials for disease relapse or for progressive or refractory disease
as a single agent
in combination with lenalidomide and dexamethasone
AIDS-Related B-Cell Lymphoma - Second-line therapy with or without rituximab for relapsed disease in noncandidates for high-dose therapy
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) - Treatment for CLL without del(17p) or with or without del(11q)
as first-line therapy with or without rituximab for stage II-IV disease
with or without rituximab for relapsed or refractory disease
Diffuse Large B-Cell Lymphoma - Second-line therapy with or without rituximab for relapsed or refractory disease in noncandidates for high-dose therapy
Follicular Lymphoma - Used in patients with the indications for treatment as
first-line therapy in combination with rituximab
second-line or subsequent therapy as a single agent or in combination with rituximab
Gastric MALT Lymphoma - Used in patients with the indications for treatment as
first-line therapy in combination with rituximab
second-line therapy for recurrent or progressive disease as a single agent or in combination with rituximab
Mantle Cell Lymphoma -- Used as
less aggressive induction therapy with rituximab
second-line therapy with or without rituximab for relapsed, refractory, or progressive disease
Nongastric MALT Lymphoma - Used in patients with the indications for treatment as
first-line therapy for stage III-IV disease in combination with rituximab
second-line therapy for recurrent stage I-II disease or for progressive disease as a single agent or in combination with rituximab
Primary Cutaneous B-Cell Lymphoma
Therapy for primary cutaneous marginal zone or follicle center lymphoma as
first-line therapy for newly diagnosed generalized extracutaneous disease in combination with rituximab
second-line therapy for refractory generalized cutaneous disease or relapsed generalized extracutaneous disease as a single agent, in combination with rituximab, or as a component of BVR (bendamustine, bortezomib, and rituximab) regimen
Second-line therapy with or without rituximab for relapsed or refractory primary cutaneous diffuse large B-cell lymphoma, leg type in noncandidates for high-dose therapy
Splenic Marginal Zone Lymphoma - Used in patients with the indications for treatment as
first-line therapy in combination with rituximab for disease progression following initial treatment for splenomegaly
second-line therapy for progressive disease as a single agent or in combination with rituximab
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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