Blue Cross & Blue Shield of MississippiAll Plans · Coverage · Medical Policy · Oncology, HematologyMedium impact
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
This policy was last reviewed 06/24/2024 with no changes. A single course of ibritumomab tiuxetan (Zevalin) may be considered medically necessary for the treatment of relapsed or refractory CD20-positive, low-grade or follicular, B-cell non-Hodgkin lymphoma. Its use for consolidation after chemotherapy in CD20-positive follicular non-Hodgkin lymphoma with a partial or complete response may be considered medically necessary, and its use for initial treatment of follicular lymphoma may be considered medically necessary in patients unable to tolerate standard chemotherapy, such as elderly or frail patients. Consolidation of a first remission after chemotherapy for de novo aggressive B-cell NHL and use as part of a preparatory regimen before autologous or allogeneic hematopoietic cell transplantation are investigational.
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01Billing team: CPT 79403 (radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous administration) and HCPCS A9543 (yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries) are medically necessary only when the service is performed according to the policy statements.
02Before use, confirm the patient does not have more than 25% bone marrow involvement by lymphoma and does not have impaired bone marrow reserve (platelet count under 100,000/mm3 or neutrophil count under 1500/mm3), since the policy recommends these agents not be used in those patients.
03Consolidation of a first remission after chemotherapy for de novo aggressive B-cell NHL, and use in a preparatory regimen before hematopoietic cell transplantation, are investigational, and BCBSMS makes no payment for services not documented to be Medically Necessary.
Codes mentioned
79403A9543C82.00C82.99C85.10C85.29
Original notice
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
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