00150
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Liver-directed administration of high-dose melphalan (Hepzato Kit) is consideredmedically necessarywhenallof the following criteria are met:
- 18 years of age or older;and
- Weight of at least 35 kilograms (77 pounds);and
- Metastatic uveal melanoma, whenallthe following criteria are met;Unresectable hepatic liver metastases, confirmed on imaging (computed tomography [CT] or magnetic resonance imaging [MRI]);andLiver metastases affect no more than 50% of the liver;andIf extra-hepatic disease is present, it is:Limited to the bone, lymph nodes, subcutaneous tissues, or lung;andAmenable to either, resection or radiation;and
- Unresectable hepatic liver metastases, confirmed on imaging (computed tomography [CT] or magnetic resonance imaging [MRI]);and
- Liver metastases affect no more than 50% of the liver;and
1 Active Policy
ANTHEM-MED.00150 — MED.00150 Hepzato Kit⢠(melphalan hepatic delivery system)
Related Codes
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