Download NCCN Compendium

New UnitedHealthcare Chemotherapy Drug Policy – Questions and Answers
1. What is the National Comprehensive Cancer Network?
The National Comprehensive Cancer Network (NCCN) is an alliance of 21 of the world’s
leading cancer centers, working together to develop treatment guidelines for most cancers,
and dedicated to research that improves the quality, effectiveness, and efficiency of cancer
care. The NCCN offers a number of programs to give clinicians access to tools and
knowledge that can help guide decision-making in the management of cancer. NCCN creates
clinical practice guidelines appropriate for use by patients, clinicians, and other health care
decision-makers.
2. How will UnitedHealthcare use the NCCN Compendium?
The NCCN Drugs & Biologics Compendium™ is a well respected source of information for
treating cancer written by cancer specialists. Oncologists, as well as case managers,
managed care decision-makers, and other health care professionals who authorize treatment
for patients can all use this source of information for sound clinical decisions.
UnitedHealthcare will be using the guidelines as our primary source for chemotherapy
coverage decisions. Moving to one source will allow treating physicians and members alike
an easy way to better understand what chemotherapy agents are eligible for reimbursement
by UnitedHealthcare.
Proposed or billed therapies that are not listed with a 1, 2A, or 2B recommendation by the
NCCN are reviewed by the UnitedHealthcare clinical review team. Member certificate of
coverage and/or state mandates will be included in this review process.
3. How often does the NCCN update their compendium?
The NCCN Drugs & Biologics Compendium™ is updated in conjunction with the NCCN
Clinical Practice Guidelines in Oncology™ on a continual basis (at least monthly). The latest
NCCN Guidelines and Compendium updates can be accessed at nccn.org.
4. What recommendation levels from the NCCN Compendium will be used by
UnitedHealthcare to determine coverage for chemotherapy drugs administered in an
outpatient setting?
If the NCCN compendium lists the drug with a recommendation 1, 2A, or 2B for the condition,
the service is eligible for reimbursement based on the member’s certificate of coverage. In
general, we do not cover recommendations with Level 3 evidence.
Category of Evidence and
Consensus
Quality of Evidence
Level of Consensus
1
High
Uniform
2A
Lower
Uniform
2B
Lower
Non-uniform
3
Any
Major disagreement
5. Why has UnitedHealthcare decided not to provide coverage for drug/
diagnosis combinations with an NCCN category 3 recommendation?
According to the NCCN, drug/diagnosis combinations are assigned a category 3
recommendation because there is major disagreement among the panel members
about the significance of the clinical trials. Panel members are not able to reach an
agreement about the effectiveness of the drug for this diagnosis. The category 3
designation alerts clinicians to a major interpretation issue in the data and an
explanation is provided in the guidelines. These drug/diagnosis combinations will
be reviewed by our clinical review team and if services are determined to not be
eligible for coverage, they will be denied as unproven.
6. If a drug claim is submitted and the category of evidence is a 3, or the drug is not
listed on the NCCN compendium for a certain diagnosis, what action will
UnitedHealthcare take?
Proposed or billed therapies that are not listed with a 1, 2A, or 2B recommendation by the
NCCN are reviewed by the UnitedHealthcare clinical review team. Member certificate of
coverage and/or state mandates will be included in this review process.
7. The NCCN guidelines also address supportive care drugs. Is UnitedHealthcare
using the guidelines for supportive care drugs like Erythropoietin (EPO)?
The NCCN compendium will be used for injectable chemotherapy agents (J9000-J9999).
Supportive care drugs (those drugs used by oncologists to treat nausea, vomiting, pain,
anemia, and low white blood cell counts) are not included in this drug policy. We will
continue to follow our standard process for these drugs.
8. Which UnitedHealthcare members are being impacted?
The drug policy applies to most benefit plans sponsored or administered by
UnitedHealthcare. It does not apply to members enrolled in benefit plans insured or
administered by Oxford® Health Plans, UnitedHealthcare Plans of the River Valley (f/k/a
John Deere Health), Golden Rule®, PacifiCare®, Neighborhood Health Plan, American
Medical Security® Life Insurance Co. or our other affiliated companies. The policy also
does not apply to members enrolled in government programs such as AmeriChoice,
Ovations, SecureHorizons, or Medicare Advantage.
9. When is the UnitedHealthcare new chemotherapy drug policy effective?
Changes to the new chemotherapy drug policy are effective March 15, 2008.
10. Where can clinicians view UnitedHealthcare’s new drug policy?
Clinicians can view UnitedHealthcare’s Drug Policy at UnitedHealthcareOnline.com >
Tools & Resources > Policies & Protocols > Medical Policies > Oncology
Medication Clinical Coverage Policy.
11. How do clinicians access the NCCN Clinical Practice Guidelines in Oncology™ and
NCCN Drugs & Biologics Compendium™?
Clinicians will access through the NCCN Web site at nccn.org. Links to compendiums are
available on the home page of NCCN site.
12. How do patients access the NCCN/ACS Treatment Guidelines for Patients?
Patients will access through the NCCN Web site at nccn.org. A link to the NCCN/ACS
Treatment Guidelines for patients is available on the home page of NCCN site.