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Palifermin (Kepivance) (CPB 0851, reviewed 2025-12-22)
Effective date
Not stated in the notice
Identified
Aug 13, 2026
Summary
Aetna considers palifermin (Kepivance) medically necessary for the prevention and treatment of severe oral mucositis in members with hematologic malignancies receiving myelotoxic therapy and requiring autologous hematopoietic cell transplantation, using preparative regimens predicted to result in WHO grade 3 or 4 oral mucositis in the majority of members. All other indications are considered experimental, investigational, or unproven. Continuation of therapy is medically necessary for members who have experienced benefit from an approved indication. The policy was last reviewed on December 22, 2025.
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What to do
Action · 8 steps
01Covered when criteria are met: palifermin (HCPCS J2425, injection, palifermin, 50 micrograms) is covered for severe oral mucositis in members with hematologic malignancies receiving myelotoxic therapy who require autologous hematopoietic cell transplantation, using preparative regimens predicted to result in WHO grade 3 or 4 oral mucositis in the majority of members.
02ICD-10 codes C81.00 through C88.91 (for those members) and K12.31 are listed as covered when those criteria are met.
03Dosing in the policy is 60 mcg/kg/day as an intravenous bolus for 3 consecutive days before and 3 consecutive days after myelotoxic therapy, six doses in total.
04The third pre-therapy dose is given 24 to 48 hours before myelotoxic therapy.
05The first post-therapy dose is given on the day of hematopoietic stem cell infusion after the infusion is completed, and at least 7 days after the most recent administration of Kepivance.
06Palifermin is experimental, investigational, or unproven for the listed indications, including inhibition or treatment of graft-versus-host disease, mitigation of dysphagia in lung cancer, and treatment of alimentary/gastrointestinal mucositis.
07ICD-10 codes D89.810 (acute graft-versus-host disease), K11.9 and R68.2 are listed as not covered for the indications in the policy.
08Continuation of therapy is medically necessary for members who have experienced benefit from an approved indication.
Codes mentioned
382403824138242J2425J9250J9255J9260K12.31D89.810K11.9R68.2
Original notice
Palifermin (Kepivance) (CPB 0851, reviewed 2025-12-22)
aetna.com · Always check the source before changing claims.
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