A. Vandetanib is considered medically indicated in the treatment of metastatic or unresectable locally advanced medullary thyroid cancer (symptomatic or progressive)..
B. The decision to treat a patient with vandetanib must be based on the following criteria:
a. Base Electrocardiogram
b. Base electrolyte as: K, Ca and Mg
c. Base TSH
C. By Triple-S, it is considered for payment for the treatment with vendetanib in the following conditions, identified by their corresponding ICD-10 codes.
D. Triple-S does not consider for payment the use of vandetanib under the following circumstances:
a. When there is documentation of:
i. Congenital syndrome with prolongation of the QT segment
ii. <18 years of age Off label indication; Non-Small Cell Lung Cancer ; Patient’s tumor is confirmed to have RET gene rearrangements