Ibritumomab Tiuxetan (Zevalin)

Covered for relapsed/refractory low‑grade or follicular B‑cell NHL and as consolidation after partial/complete response to first‑line chemotherapy; repeat courses are not medically necessary and all other indications (e.g., Burkitt, CLL, mantle cell, MALT, PTLD, hepatocellular carcinoma and listed ICD‑10 codes) are considered experimental/investigational and not covered. Must be given only as the Zevalin regimen (rituximab Day 1, then rituximab followed ~4 hours later by Y‑90 ibritumomab tiuxetan on Day 7–9); do not administer if platelets <100,000/mm3 and platelets must be ≥150,000/mm3 for the standard 0.4 mCi/kg dose (CPT 79403 covered if criteria met).

"Other related CPT codes (when selection criteria are met / related to service): 78800-78804 (radiopharmaceutical localization/distribution), 85032 (manual blood count), 85049 (platelet, automated),..."

Sign up to see full coverage criteria, indications, and limitations.