The principal pharmacologic action of Ixabepilone (Ixempra®) in cancer patients is halting cell division by inhibiting microtubules in the mitotic phase, leading to cell death. Ixabepilone (Ixempra) also demonstrates synergistic antitumor activity in combination with capecitabine in vivo.
Food and Drug Administration (FDA) Indications
Ixabepilone (Ixempra) may be considered medically necessary when ANY ONE of the following criteria is met:
Ixabepilone (Ixempra) is considered experimental/investigational for all other indications and therefore, non-covered. Scientific evidence does not support the use for any other indications than those listed above.
J9207 |
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National Comprehensive Cancer Network (NCCN) Recommendations
Ixabepilone (Ixempra) may be considered medically necessary when ANY ONE of the following criteria is met:
o With symptomatic visceral disease or visceral crisis; or
o That is hormone receptor-negative or hormone receptor-positive and endocrine therapy refractory; or
o With symptomatic visceral disease or visceral crisis; or
o That is hormone receptor-negative or hormone receptor-positive and endocrine therapy refractory.
Ixabepilone (Ixempra) is considered experimental/investigational for all other indications and therefore, non-covered. Scientific evidence does not support the use for any other indications than those listed above.
J9207 |
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Other Medically Accepted Non-FDA Approved Indications, Class IIb or Higher Grade Recommendation
Ixabepilone (Ixempra) may be considered medically necessary when used in the treatment of metastatic hormone refractory prostate cancer.
Ixabepilone (Ixempra) is considered experimental/investigational for all other indications and therefore, non-covered. Scientific evidence does not support the use for any other indications than those listed above.
J9207 |
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NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Covered Diagnosis Codes for Procedure Code J9207:
C50.011 |
C50.012 |
C50.019 |
C50.021 |
C50.022 |
C50.029 |
C50.111 |
C50.112 |
C50.119 |
C50.121 |
C50.122 |
C50.129 |
C50.211 |
C50.212 |
C50.219 |
C50.221 |
C50.222 |
C50.229 |
C50.311 |
C50.312 |
C50.319 |
C50.321 |
C50.322 |
C50.329 |
C50.411 |
C50.412 |
C50.419 |
C50.421 |
C50.422 |
C50.429 |
C50.511 |
C50.512 |
C50.519 |
C50.521 |
C50.522 |
C50.529 |
C50.611 |
C50.612 |
C50.619 |
C50.621 |
C50.622 |
C50.629 |
C50.811 |
C50.812 |
C50.819 |
C50.821 |
C50.822 |
C50.829 |
C50.911 |
C50.912 |
C50.919 |
C50.921 |
C50.922 |
C50.929 |
C61 |
Z85.3 |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.