A9607 — Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Physician attestation is required when requesting a non-preferred product: physician must attest that the same intolerance, contraindication, or adverse event would not be expected to occur with the respective non-preferred product.
- Coverage determinations must reference NCCN Drugs & Biologics Compendium listings and the Categories of Evidence and Consensus (1, 2A, 2B supported as medically necessary; Category 3 not medically necessary) as the evidentiary basis.
- Member specific benefit plan document must be consulted and referenced to determine coverage; in the event of conflict, the member specific benefit plan governs.
- For CAR-T/TIL therapies, documentation and decisions are based on OptumHealth Transplant Solutions criteria and the Clinical Guideline titled Chimeric Antigen Receptor T-cell (CAR T) Therapy, Tumor-Infiltrating Lymphocyte (TIL) Cell Therapy.
Key Coverage Criteria
- This policy provides parameters for coverage of injectable oncology medications (including, but not limited to octreotide acetate, leuprolide acetate, leucovorin, and levoleucovorin), including therapeutic radiopharmaceuticals, covered under the medical benefit based upon the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium® (NCCN Compendium®).
- UnitedHealthcare recognizes indications and uses of injectable oncology medications, including therapeutic radiopharmaceuticals, listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, and 2B as proven and medically necessary, and Categories of Evidence and Consensus of 3 as unproven and not medically necessary.
- UnitedHealthcare will cover all chemotherapy agents for individuals under the age of 19 years for oncology indications.
- Mvasi (bevacizumab-awwb) — Indications: All oncology indications.
- Kanjinti (trastuzumab-anns), Trazimera (trastuzumab-qyyp), Ogivri (trastuzumab-dkst) as preferred alternatives to Herceptin and other trastuzumab products — Indications: All oncology indications.
- Kanjinti (trastuzumab-anns) + Perjeta (pertuzumab) and other listed biosimilar trastuzumab combinations — Indications: All oncology indications.
5 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
CARELON-therapeutic-radiopharmaceuticals-2025-03-23 — Therapeutic Radiopharmaceuticals
UHC-POL-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
UMR-POL-UMR-oncology-medication-clinical-coverage-policy — Oncology Medication Clinical Coverage
Related Codes
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