Polatuzumab vedotin-piiq (Polivy) is considered medically necessary for the treatment of adult patients with diffuse large B-cell lymphoma (DLBCL) when the following criteria are met:
• The patient has relapsed or refractory disease; and
• Polatuzumab vedotin is administered in combination with bendamustine and a rituximab product; and
• The patient has received at least two prior systemic chemotherapies; and
• The patient is not a candidate for autologous hematopoietic stem cell transplantation (HSCT);
and
• The patient has not previously undergone allogeneic HSCT; and
• The patient does not have active central nervous system lymphoma or histologically transformed lymphoma.
Authorization: 12 months
Use of polatuzumab vedotin-piiq (Polivy) may be considered medically necessary for clinical indications not listed above when the drug is prescribed for the treatment of cancer either:
• In accordance with FDA label (when clinical benefit has been established, (see Policy
Guidelines); OR
• In accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached.
