Download review request for

REVIEW REQUEST FOR
Bevacizumab (Avastin®)
For Non-Ophthalmologic Indications
Provider Data Collection Tool Based on Medical Policy DRUG.00038
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
11/05/2015
Request Date:
/
Initial Request
Buy and bill
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Policy Effective Date
01/05/2016
Provider Tool Effective Date
Subsequent Request
Individual’s Name:
Date of Birth:
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Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
01/05/2016
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Provider ID Number (if known) :
Office Address:
Contact Person and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Contact Person and Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
Avastin®
J9035
Other:
When did the individual first start this drug?
/
/
Duration:
(Weeks)
(mg/kg)
(other)
Frequency (Days, Wks, Months)
Start Date For This Request:
/
/
Please check all that apply to the individual:
Complete this section before proceeding to the following disease specific sections:
Please check if the individual has been treated with any chemotherapy medications in the past
(If checked, provide the chemotherapy medications that the individual has received):
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REVIEW REQUEST FOR
Bevacizumab (Avastin®)
For Non-Ophthalmologic Indications
Provider Data Collection Tool Based on Medical Policy DRUG.00038
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
11/05/2015
Policy Effective Date
01/05/2016
Provider Tool Effective Date
01/05/2016
(1) Metastatic Breast Cancer
Individual has been diagnosed with metastatic breast carcinoma
Avastin® will be used for first line chemotherapy (Note: Hormonal therapy alone is NOT considered
“chemotherapy”)
Individual has been diagnosed with HER2-negative breast cancer
Individual will receive Avastin® in combination with paclitaxel
Individual will receive Avastin® in combination with paclitaxel protein-bound
Individual will NOT be receiving other targeted biologic agents at the same time
Other
(2) Primary Central Nervous System Tumor
Individual has been diagnosed with a primary central nervous system tumor.
Individual has failed radiation therapy
Avastin® is used in a single line of therapy
Tumor to be treated is a World Health Organizaion (WHO) Grade III/IV glioma
(If checked, please indicate the glioma type)
Anaplastic astrocytoma
Progressive or recurrent ependymoma
Anaplastic glioma
Recurrent high-grade glioma
Glioblastoma
Glioblastoma multiforme
Other
Individual will NOT be receiving other targeted biologic agents at the same time
Other
(3) Metastatic Cervical Cancer
Individual has been diagnosed with metastatic cervical cancer
Individual has recurrent or persistent disease that is not amendable to curative treatment with
surgery or radiotherapy
Avastin® will be used in a single line of therapy
Avastin® will be used in combination with paclitaxel and topotecan chemotherapy
Avastin® will be used in combination with paclitaxel and cisplatin chemotherapy
Individual will NOT be receiving other targeted biologic agents at the same time
Other
(4) Metastatic Colon, Rectal, Colorectal, or Small Bowel Adenocarcinoma
Individual has been diagnosed with metastatic colon, rectal, colorectal, or small bowel adenocarcinoma
Individual will receive Avastin® in combination with 5-fluorouracil (5-FU)-based chemotherapy as
first-line treatment
Individual will receive Avastin® in combination with 5-FU-based chemotherapy, irinotecan, or
oxaliplatin as second-line treatment
Individual has progressed on a first-line Avastin® containing regimen AND will receive
Avastin® in combination with 5FU-based chemotherapy, irinotecan or oxaliplatin as second-line treatment
Individual will NOT be receiving other targeted biologic agents at the same
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REVIEW REQUEST FOR
Bevacizumab (Avastin®)
For Non-Ophthalmologic Indications
Provider Data Collection Tool Based on Medical Policy DRUG.00038
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
11/05/2015
Policy Effective Date
01/05/2016
Provider Tool Effective Date
01/05/2016
Other
(5) Non-Squamous Non-Small Cell Lung Cancer (NSCLC)
Individual has been diagnosed with NSCLC. (If checked, mark all of the following that apply)
Cancer is unresectable
Cancer is locally advanced
Cancer is recurrent
Cancer is metastatic
Initial Treatment for NSCLC:
Avastin® will be used as first line therapy in the initial treatment of NSCLC
Individual with performance status 0 -1
Individual with no history of hemoptysis
Individual will receive Avastin® with platinum-based therapy (If checked indication the combination
treatment)
Will receive in combination with taxane
Will receive in combination with pemetrexed (Alimta®)
Individual will NOT be receiving other targeted biologic agents at the same time
Other
Maintenance Treatment for NSCLC:
Avastin® to be used as maintenance therapy for NSCLC
Avastin® was used as an agent in a first-line combination chemotherapy regimen
Avastin® is to be used as a single agent
Disease has NOT progressed since this treatment regimen started
Avastin® may be used until disease progression
Individual will NOT be receiving other targeted biologic agents at the same time
Other
(6) Metastatic Epithelial Ovarian Cancer / Fallopian Tube Cancer / Recurrent Primary Peritoneal Cancer
Individual has been diagnosed with recurrent, metastatic epithelial ovarian cancer
Individual has been diagnosed with fallopian tube cancer
Individual has been diagnosed with recurrent, primary peritoneal cancer
Avastin® will be used as a single agent or in combination with other chemotherapy
Avastin® will be used in a single line of therapy
Avastin® will be used for relapsed or refractory disease
Individual will NOT be receiving other targeted biologic agents at the same time
Other
(7) Post-Radiation Necrosis
Avastin® will be used to treat an individual with symptomatic post- radiation necrosis of the
central nervous system
Individual will NOT be receiving other targeted biologic agents at the same time
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REVIEW REQUEST FOR
Bevacizumab (Avastin®)
For Non-Ophthalmologic Indications
Provider Data Collection Tool Based on Medical Policy DRUG.00038
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
11/05/2015
Policy Effective Date
01/05/2016
Provider Tool Effective Date
01/05/2016
(8) Metastatic Renal Cell Carcinoma (RCC)
Individual has been diagnosed with metastatic clear cell renal carcinoma
Individual will receive Avastin® in combination with interferon as first line treatment
Individual has relapsed or medically unresectable stage IV disease with predominant clear cell histology
Individual had progressive disease while on prior cytokine therapy
Individual will receive Avastin® as single agent
Other
Individual will NOT be receiving other targeted biologic agents at the same time
Other
(9) Soft Tissue Sarcoma
Avastin® will be used as a single agent to treat an individual diagnosed with angiosarcoma
Avastin® will be used in combination with temozolomide for the treatment of solitary fibrous tumor and
Hemangiopericytoma
(10) Concomitant Use of Bevacizumab Avastin®
Avastin® will NOT be used to treat a single condition when the individual is also receiving
other targeted biologic agents (including, but not limited to erlotinib, cetuximab, panitumumab, trastuzumab,
lapatinib, and ziv-aflibercept)
Other
(11) Other Indication not otherwise specified
(Please submit all supporting documents including labs, progress notes, imaging, etc., for review.)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported
on this form.
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/
Name & Title of Provider or Provider Representative Completing Form
Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
.
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REVIEW REQUEST FOR
Bevacizumab (Avastin®)
For Non-Ophthalmologic Indications
Provider Data Collection Tool Based on Medical Policy DRUG.00038
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
11/05/2015
Policy Effective Date
01/05/2016
Provider Tool Effective Date
01/05/2016
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management
services on behalf of your health benefit plan or the administrator of your health benefit plan.
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