Mountain State Medical Policy Bulletin
Section: Injections
Number: I-79
Topic: Plerixafor (Mozobil™)
Effective Date: January 1, 2010
Issued Date: May 31, 2010
Date Last Reviewed: 07/2009

General Policy Guidelines

Indications and Limitations of Coverage

Coverage for plerixafor (Mozobil)(J2562) is determined according to individual or group customer benefits.

Plerixafor is to be used in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with multiple myeloma or non-Hodgkin's lymphoma.

Plerixafor administration is initiated after the patiet has received G-CSF once daily for 4 days. The plerixafor dose is repeated up to 4 consecutive days. The dose is selected based on 0.24 mg/kg actual body weight. Plerixafor is administered by subcutaneous injection approximately 11 hours prior to initiation of apheresis.

The use of plerixafor for any diagnosis not listed on this policy is considered experimental/investigational, and therefore, not covered. A participating, preferred, or network provider can bill the member for the non-covered service.

Description

Plerixafor is a hematopoietic stem cell mobilizer and inhibitor of the CXCR4 chemokine receptor. CXXR4 is specific for stromal-derived-factor 1 (SDF-1), a molecule endowed with potent chemotactic activity for lymphocytes. Because the interaction between SDF-1 and CXCR4 plays an important role in holding hematopoietic stem cells in the bone marrow, drugs that block the CXCR4 receptor appear to be capable of mobilizing hematopoietic stem cells into the bloodstream.


NOTE:
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 circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

J2562     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious life-threatening condition and when medically necessary and appropriate for the patient’s condition.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Mozobil (plerixafor)[Prescribing Information]. Cambridge, MA:Genzyme Corporation;2008.

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Multiple Myeloma. V 2. 2009. Available at: http://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf.

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Non-Hodgkin's Lymphomas. V 2. 2009. Available at: http://www.nccn.org/professionals/physician_gls/pdf/nhl.pdf.

Brenner H, Gondos A, Pulte D. Recent major improvement in long-term survival of younger patients with multiple myeloma. Blood. 2008;111:2521-2526.

Kumar SK, Rajkumar SV, Dispenziere A, et al. Improved survival in multiple myeloma and the impact of novel therapies. Blood. 2008;111:2516-2520.

Plerixafor: AMD 3100, JM 3100, SDZS1D791. Drugs RD. 2007;8:113-119.

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[Version 002 of I-79]
[Version 001 of I-79]

Table Attachment

Text Attachment


 

Procedure Code Attachments

Diagnosis Codes

202.80-202.88203.00-203.02  

Glossary




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 circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.