J7513, Daclizumab, parenteral, 25 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records documenting absence of contraindicated prior toxicities for retreatment (e.g., no prior sustained VT ≥5 beats, uncontrolled arrhythmias, prolonged intubation/dialysis, prolonged coma/toxic psychosis, bowel ischemia/perforation, GI bleeding requiring surgery, etc.).
- Monitoring and adverse event documentation (evidence of monitoring for capillary leak syndrome, infections, neurologic status, hemodynamics) as part of treatment records.
- Any other clinical notes, imaging, or lab data supporting clinical indication (tumor response assessments, pathology, staging) as relevant to the indication.
- Records of prior drug‑related toxicities from earlier IL‑2 courses (to assess contraindications to retreatment), including any occurrences of sustained ventricular tachycardia, uncontrolled arrhythmias, chest pain with ECG changes, cardiac tamponade, prolonged intubation, dialysis‑requiring renal failure, coma/toxic psychosis, refractory seizures, bowel ischemia/perforation, or GI bleeding requiring surgery.
Key Coverage Criteria
- Cutaneous melanoma — as high-dose single-agent subsequent therapy for metastatic or unresectable disease
- Metastatic melanoma (FDA‑approved indication for treatment of adults with metastatic melanoma)
- Metastatic renal cell carcinoma with clear cell histology (FDA‑approved indication for treatment of adults with metastatic renal cell carcinoma)
- Chronic graft‑versus‑host disease (GVHD) — for treatment as additional therapy in conjunction with systemic corticosteroids following no response to first‑line therapy options
- Neuroblastoma — for treatment of neuroblastoma (see CPB 0895 - Dinutuximab (Unituxin))
- Intralesional/intratumoral administration of IL‑2 for melanoma (intralesional IL‑2 CPT codes 96405/96406 covered when selection criteria met)
1 Active Policy
AETNA-CPB-0024, Aldesleukin (Proleukin)
Related Codes
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