Aetna considers clofarabine medically necessary for relapsed or refractory acute myeloid leukemia, for specified acute lymphoblastic leukemia indications including relapsed or refractory pediatric disease, for Langerhans cell histiocytosis in members 18 years of age or younger, and as conditioning for hematopoietic cell transplantation under the listed regimens. Continuation of clofarabine therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications, including B-cell lymphoma, breast cancer, Ewing sarcoma and myelodysplastic syndrome, are considered experimental, investigational, or unproven.
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01Billing team: Bill clofarabine (HCPCS J9027) with administration codes 96413 and 96415 only for the covered indications in this policy, and confirm that the claim's ICD-10 code is one listed as covered and that the selection criteria are met.
02Claims with ICD-10 codes listed as not covered for these indications, such as C50.011 (breast cancer) and C83.30 (diffuse large B-cell lymphoma), will not be covered.
03For continuation of therapy, document that there is no evidence of unacceptable toxicity or disease progression on the current regimen.
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