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IPILIMUMAB (YERVOY) – INTRAVENOUS CHEMOTHERAPY

Treatment of metastatic melanoma or non-resectable malignant melanoma stage III and IV with ipilimumab is considered medically necessary in patients 18 years or older.
Yervoy also may be considered medically necessary in patients 18 years of age or older for cutaneous melanoma as adjuvant therapy in patients with pathologic involvement of regional lymph nodes of more than 1 mm and the patient has undergone complete resection, including total lymphadenectomy;

A.    Triple-S considers for payment the treatment with Ipilimumab under the following conditions, identified by their corresponding ICD-10 codes:

1. Unresectable or metastatic melanoma

2. Cutaneous melanoma (Stage III)

a. Used as adjuvant therapy

b. Pathologic involvement of regional lymph nodes of more than 1 mm

c. Patient has undergone complete resection, including total lymphadenectomy

3. Central nervous system (CNS) metastases

a. Yervoy was active against the primary tumor (melanoma)

b. Member has recurrent disease

4. Advanced renal cell carcinoma

a. Patient is considered to have an intermediate or poor prognosis

i. Used In combination with nivolumab (Opdivo)

5. Microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer

a. Disease progression following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan

b. Diagnosis has to be confirmed by PCR-based assay genetic testing

c. Used in combination with nivolumab (Opdivo)

6. Melanoma , metastatic with brain metastases (Off label use)

7.Hepatocellular carcinoma who have been previously treated with sorafenib, in combination with nivolumab.

Triple-S does not consider for payment the use of Ipilimumab under the following circumstances:

a.     When there is documentation of:

i.    Pregnancy

ii.    Nursing mothers

iii.    Patients with hepatic or renal impairment

iv.    < 12 years of age

787-277-6653 787-474-6326