- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines;Payer Specific
Supporting Documentation Requirements: 2 of Chart Notes;IDH1 mutation as detected by an FDA-approved test
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Use of Biomarkers in Policy: IDH1 mutation
Diagnosis Types: 1 of >=60 years and not a candidate for intensive remission induction therapy;Post induction therapy;Relapsed or refractory AML with an IDH1 mutation as detected by an FDA-approved test
Excludes Coverage in Maintenance Setting: No
Cholangiocarcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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