Clinical UM Guideline
|Subject:||White Blood Cell Growth Factors|
|Guideline #:||CG-DRUG-16||Current Effective Date:||01/01/2014|
|Status:||Revised||Last Review Date:||05/09/2013|
White blood cell growth factors, also known as colony stimulating factors (CSF), are administered to enhance recovery of blood related functions in neutropenia (low white blood count) including febrile neutropenia (FN). CSFs are also utilized to decrease the incidence and severity of infection associated with select disease-related and drug-related myelosuppression (inhibition of bone marrow function).
Granulocyte colony stimulating factors (G-CSF) are glycoproteins which exert major control over the reproduction and maturation of certain white blood cells, which include:
Granulocyte-macrophage colony stimulating factor (GM-CSF) is a hematopoietic growth factor which stimulates proliferation and differentiation of hematopoietic progenitor cells.
Note: See Definition section for definition of febrile neutropenia.
Not Medically Necessary:
The use of CSFs (filgrastim, pegfilgrastim, sargramostim and tbo-filgrastim) is considered not medically necessary for any of the following:
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|J1442||Injection, filgrastim (G-CSF), 1 microgram [Neupogen]|
|J1446||Injection, tbo-filgrastim, 5 micrograms [Granix]|
|J2505||Injection, pegfilgrastim, 6 mg [Neulasta]|
|J2820||Injection, sargramostim (GM-CSF), 50 mcg [Leukine, Prokine]|
|S9537||Home therapy; hematopoietic hormone injection therapy (e.g. erythropoietin, G-CSF, GM-CSF); per diem [when specified as G-CSF, GM-CSF]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
Filgrastim, Pegfilgrastim, Sargramostim:
Filgrastim, pegfilgrastim and sargramostim are recombinant colony-stimulating factors (CSFs) approved by the U.S. Food and Drug Administration (FDA) for stimulation, proliferation, differentiation of neutrophils, and end cell functional activation of hematopoietic cells.
The American Society of Clinical Oncology (ASCO, Smith) 2006 Update of Recommendations for the Use of White Blood Cell Growth Factors: An Evidence-Based Clinical Practice Guideline was adapted for the oncologic indications in this document. Additional non-FDA approved indications are based on expert consensus guidelines (National Comprehensive Cancer Network® [NCCN®] Clinical Practice Guidelines in Oncology and European Organisation for Research and Treatment of Cancer [EORTC; Aapro, 2011]), drug compendia and published peer reviewed literature as detailed in CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use.
Neutropenia, a decreased number of neutrophils (white blood cells which fight infection) in the blood is commonly caused by chemotherapy, and often results in hospitalization. Neutropenia occurs when myelosuppressive chemotherapeutic treatments reduce the neutrophil counts. The risk of infection increases as the absolute neutrophil count (ANC) drops below 1,000/microL (Crawford, 2004; Dale, 2002). Febrile neutropenia can occur as a result of severe neutropenia. Febrile neutropenia is defined as the occurrence of fever (greater than 38.3oC for more than 1 hour) in association with an ANC less than 0.5 x 109/L, but some studies have used an ANC less than 1.0 x 109/L as the threshold (Dale, 2002; NCCN, 2012). The severity of neutropenia is related to the intensity and type of the chemotherapy regimen, individual-risk factors, and disease-related factors (NCCN, 2012; Ozer, 2000; Smith, 2006). Colony stimulating factors (CSFs) are used to prevent severe neutropenia, reduce the duration of neutropenia, prevent febrile neutropenia, and infection-related complications in individuals with cancer. The routine use of CSFs in neutropenic individuals who are afebrile is not recommended (Smith, 2006).
According to ASCO, no guideline recommendation can be made regarding the equivalency of the two colony-stimulating agents, G-CSF (filgrastim) and GM-CSF (sargramostim). There is currently no data available to support preferential use of filgrastim or pegfilgrastim in the treatment of febrile neutropenia. Similarly, there is no currently available data to support preferential use of filgrastim or sargramostim in the treatment of AML, mobilization of progenitor cells, or following autologous or allogeneic bone marrow transplant (Smith, 2006). Further trials are recommended to study the comparative clinical activity, toxicity, and cost effectiveness of G-CSF and GM-CSF.
The currently available agents differ in their pharmacokinetic properties. Both sargramostim and filgrastim can be administered intravenously (IV) or subcutaneously (SC), whereas pegfilgrastim is administered only SC. Pegfilgrastim is a pegylated form of filgrastim developed to allow for less frequent dosing. Although the two agents have the same mechanism of action, pegfilgrastim has reduced renal clearance and prolonged persistence in vivo compared to filgrastim (Product Information Labels, 2009; 2011; 2012).
Pegfilgrastim (Neulasta) is not labeled for use in myeloid malignancies as it has not been studied for this indication. According to the product information label (2011), the possibility pegfilgrastim acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, cannot be excluded.
Standard practice in protecting against chemotherapy-associated infection has been chemotherapy dose modification or dose delay, administration of progenitor-cell support, or selective use of prophylactic antibiotics. Chemotherapy associated neutropenic fever or infection has customarily involved treatment with intravenous antibiotics, usually accompanied by hospitalization. The hematopoietic CSFs have been introduced into clinical practice as additional supportive measures to reduce the likelihood of neutropenic complications due to chemotherapy in individuals who are at high risk.
The NCCN® Clinical Practice Guidelines in Oncology™ on Myeloid Growth Factors (2012), ASCO (Smith, 2006) and EORTC (Aapro, 2011) recommend the assessment of risk for chemotherapy induced FN prior to initiating the first cycle of chemotherapy. Factors in the evaluation include disease type, individual risk factors, the intent of treatment and the type of chemotherapeutic regimen. The risk stratification includes high risk (greater than 20% risk of FN), intermediate risk (10-20% risk) and the low risk (less than 10% risk) groups. NCCN recommends routine CSFs for primary prophylaxis of FN for individuals in the high risk group. For individuals in the intermediate risk (10-20%), NCCN notes CSFs may be considered for primary prophylaxis when additional risk factors are present that would increase the individual's risk of FN (e.g. age greater than 65). Routine use of CSF is not recommended as primary prophylaxis of FN when an individual is considered a low risk. However, NCCN notes for low-risk individuals, "CSF may be considered if the individual is receiving curative or adjuvant therapy and is at significant risk for serious medical consequences of FN, including death." Schnipper (2012) and colleagues reaffirmed the ASCO guidelines recommend "using white cell stimulating factors when the risk of febrile neutropenia, secondary to a recommended chemotherapy regimen is approximately 20% and equally effective treatment programs that do not require white cell stimulating factors are unavailable." Independent clinical judgment based on the individual's clinical situation facilitates identifying the appropriate risk group. After the initial treatment cycle and prior to each subsequent cycle, a risk categorization should be evaluated. If FN or a dose-limiting neutropenic event occurred with the previous cycle of treatment with the same dose and schedule planned for the current cycle, the individual is now in the high risk group (NCCN, 2012). The use of white blood cell growth factors as prophylaxis is recommended for individuals considered at high-risk for febrile neutropenia, regardless if the treatment is intended to be curative, to prolong survival or to manage symptoms. In all risk categories, low-, intermediate- and high-risk for chemotherapy-induced neutropenia or other neutropenic-related events that may compromise or delay treatment, careful discussion to determine the risks and benefits of CSF use is recommended (NCCN, 2012).
The EORTC guidelines (Aapro, 2011) note for dose dense (increased frequency) or dose-intense (increased dose) chemotherapy "multiple studies have confirmed that, because the time to neutrophil recovery is around 12 days, pegfilgrastim can be conveniently administered together with chemotherapy in patients receiving treatment at 14 days intervals." The NCCN Clinical Guidelines for Myeloid Growth Factors (2012) note dose-dense regimens with CSF support "improved disease-free and/or overall survival compared to conventional chemotherapy." In addition, specialty consensus opinion suggests white blood cell growth factors are used with dose dense chemotherapy regimens in the adjuvant setting to treat individuals with breast cancer.
Neutropenia also commonly occurs in individuals with human immunodeficiency virus (HIV) with 10% to 20% of individuals with early disease experiencing cytopenias and in 35% to 75% of individuals with advanced HIV (Kuritzkes, 2000). Neutropenia, defined as an absolute neutrophil count [ANC] less than 1000 x 109/L, may be resulting from multiple factors in individuals with HIV. Additionally, neutropenia may be compounded by frontline treatment that may have myelosuppressive effects. Granulocyte colony stimulating factors have been used in individuals with HIV to stimulate granulopoiesis and increase circulating lymphocyte counts (Kuritzkes, 2000).
The American Hospital Formulary Service® (AHFS®, 2013) notes filgrastim has been used effectively to treat neutropenia in a small number of individuals receiving myelosuppressive drugs for nonmalignant conditions. Additionally, the AHFS notes filgrastim has been used to increase neutrophil counts for severe neutropenia in individuals with hairy cell leukemia.
ASCO recommendations for the management of individuals exposed to lethal doses of total body radiotherapy or accidental total body radiation include the administration of CSFs or pegylated G-CSF. The recommendation is based on observation of cases in the Radiation Emergency Assistance Center Training Site in the Radiation Accident Registry Center (REAC/TS registry). Twenty-five of 28 individuals experienced enhanced neutrophil recovery with the use of hematopoietic growth factors after accidental radiation exposures (Smith, 2006).
The use of CSFs in conjunction with concomitant use of radiation and chemotherapy is not recommended by ASCO. Smith and colleagues (2006) stated, "in the absence of chemotherapy, therapeutic use of CSFs may be considered in individuals receiving radiation therapy alone if prolonged delays secondary to neutropenia are expected."
Other Proposed Uses:
The use of sargramostim to induce remission in Crohn's disease has been proposed. In a Cochrane review (Roth, 2011), a review of data from three studies did not show any difference between sargramostim and placebo drug to induce remission or clinical improvement for individuals with active Crohn's disease. The investigators recommended randomized controlled trials to research the effects of sargramostim on Crohn's disease (Roth, 2011).
Multiple phase I and phase II clinical trials are studying the safety and efficacy of sargramostim to treat malignant melanoma. However, the published data have been primarily from smaller series that included a variety of additional immunomodulatory agents and outcomes were mixed. Investigators have noted the outcomes from larger randomized phase III trials with longer followup are needed.
There is moderate evidence from three separate systematic reviews which showed CSFs should not be used routinely for the prevention or treatment of non-chemotherapy induced infection, specifically, neonatal infection, and diabetic foot infections or as an adjunct to antibiotics in treating non-neutropenic adults with pneumonia (Carr, 2003; Cheng, 2007).
In August 2012, the FDA approved tbo-filgrastim to reduce the severe neutropenia in individuals with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. Tbo-filgrastim is a recombinant methionyl human granulocyte colony-stimulating growth factor (r-metHuG-CSF) that binds to GCSF receptors and stimulates the growth of neutrophils. Tbo-filgrastim is a biosimilar product to filgrastim (Neupogen) and is administered subcutaneously (del Giglio, 2008; Product Information Label, 2012).
A randomized, controlled, multinational phase III study involved 348 individuals with high-risk stage II, stage III or stage IV breast cancer who had not previously received treatment with chemotherapy. Participants were randomized in a 2:2:1 ratio to either tbo-filgrastim, a non-US-approved filgrastim product or placebo. Treatment began one day after chemotherapy for at least five days and continued to achieve an ANC of greater than or equal to 10,000 x 106/L after nadir was reached, or until a maximum of 14 days of treatment. The primary endpoint was duration of severe neutropenia (DSN) in cycle 1. Tbo-filgrastim had a superior DSN compared to placebo with a significant reduction in DSN (1.1 days compared to 3.8 days, p<0.0001). The mean DSN in cycle 1 was 1.1 days (range 0-5 days) for both tbo-filgrastim and filgrastim (Neupogen). The median time to ANC recovery in cycle 1 was 8.0 days for both tbo-filgrastim and filgrastim (Neupogen) compared to 15 days in the placebo group. The safety and effectiveness of tbo-filgrastim have not been established in individuals under 18 years of age. The FDA has required post-approval studies of tbo-filgrastim to determine the safety and efficacy in the pediatric population (del Giglio, 2008; Product Information Label, 2012).
At this time, the use of tbo-filgrastim for non-FDA approved uses is not listed in nationally recognized clinical practice guidelines or in the drug compendia.
Adverse Events and Warnings:
Product information labels for both filgrastim (Neupogen, 2012) and pegfilgrastim (Neulasta, 2011) include the following:
Serious allergic reactions, including anaphylaxis, can occur on initial or subsequent treatment.
Splenic rupture, including fatal cases, can occur following the administration of filgrastim or pegfilgrastim. Evaluate for an enlarged spleen or splenic rupture in individuals who report left upper abdominal and/or shoulder pain after receiving filgrastim or pegfilgrastim.
Acute Respiratory Distress Syndrome
Adult respiratory distress syndrome (ARDS) can occur in individuals receiving filgrastim or pegfilgrastim. Evaluate individuals who develop fever and lung infiltrates or respiratory distress for ARDS.
Sickle Cell Disorders
Severe sickle cell crises can occur in individuals with sickle cell disorders receiving filgrastim or pegfilgrastim.
Potential for Tumor Growth Stimulatory Effects on Malignant Cells
The granulocyte-colony stimulating factor (G-CSF) receptor through which pegfilgrastim and filgrastim act has been found on tumor cell lines. The possibility that filgrastim and pegfilgrastim act as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia cannot be excluded.
The safety and efficacy of growth factors given simultaneously with cytotoxic chemotherapy have not been established. Because of the potential sensitivity of rapidly dividing myeloid cells to cytotoxic chemotherapy:
Additional product information for filgrastim (Neupogen, 2012):
Alveolar Hemorrhage and Hemoptysis
Alveolar hemorrhage manifesting as pulmonary infiltrates and hemoptysis requiring hospitalization has been reported in healthy donors undergoing peripheral blood progenitor cell (PBPC) mobilization. Hemoptysis resolved with discontinuation of filgrastim. The use of filgrastim for PBPC mobilization in healthy donors is not an approved indication.
The safety and efficacy of filgrastim have not been evaluated in individuals receiving concurrent radiation therapy. Simultaneous use of filgrastim with chemotherapy and radiation therapy should be avoided.
The safety and efficacy of filgrastim use in neonates and individuals with autoimmune neutropenia of infancy have not been established.
In a phase 3 study to assess the safety and efficacy of Neupogen in the treatment of severe chronic neutropenia (SCN), 120 individuals with a median age of 12 years were studied. Of the 120 participants, 12 were infants (1 month to 2 years of age), 47 were children (2 to 12 years of age), and 9 were adolescents (12 to 16 years of age). Additional information is available from a SCN postmarketing surveillance study, which includes long-term follow-up of individuals in the clinical studies and information from additional participants who entered directly into the postmarketing surveillance study. Of the 531 participants in the surveillance study as of 31 December 1997, 32 were infants, 200 were children, and 68 were adolescents.
Children with congenital types of neutropenia (Kostmann's syndrome, congenital agranulocytosis, or Schwachman-Diamond syndrome) have developed cytogenetic abnormalities and have undergone transformation to myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML) while receiving chronic Neupogen treatment. The relationship of these events to Neupogen administration is unknown. Long-term follow-up data from the postmarketing surveillance study suggest that height and weight are not adversely affected in children who received up to 5 years of Neupogen treatment. Limited data from children who were followed in the phase 3 study for 1.5 years did not suggest alterations in sexual maturation or endocrine function.
The safety and efficacy in neonates and children with autoimmune neutropenia of infancy have not been established.
In the cancer setting‚ 12 pediatric patients with neuroblastoma have received up to 6 cycles of cyclophosphamide‚ cisplatin‚ doxorubicin‚ and etoposide chemotherapy concurrently with Neupogen; in this population‚ Neupogen was well tolerated. There was one report of palpable splenomegaly associated with Neupogen therapy; however‚ the only consistently reported adverse event was musculoskeletal pain‚ which is no different from the experience in the adult population.
Additional product information for pegfilgrastim (Neulasta, 2011)
Safety and effectiveness of Neulasta in pediatric patients have not been established. The adverse reaction profile and pharmacokinetics of pegfilgrastim were studied in 37 pediatric patients with sarcoma. The mean (± standard deviation [SD]) systemic exposure (AUC0-inf ) of pegfilgrastim after subcutaneous administration at 100 mcg/kg was 22.0 (± 13.1) mcg•hr/mL in the 6 to11 years age group (n = 10), 29.3 (± 23.2) mcg•hr/mL in the 12 to21 years age group (n = 13), and 47.9 (± 22.5) mcg•hr/mL in the youngest age group (0 to5 years, n = 11). The terminal elimination half-lives of the corresponding age groups were 20.2 (± 11.3) hours, 21.2 (± 16.0) hours, and 30.1 (± 38.2) hours, respectively. The most common adverse reaction was bone pain.
The product information label for sargramostim (Leukine, 2009) includes the following:
Benzyl alcohol is a constituent of liquid sargramostim and bacteriostatic water for injection diluents. Benzyl alcohol has been reported to be associated with a fatal "Gasping Syndrome" in premature infants. Liquid solutions containing benzyl alcohol (including liquid leukine) or lyophilized leukine reconstituted with bacteriostatic water for injection, USP (0.9% benzyl alcohol) should not be administered to neonates.
Edema, capillary leak syndrome, pleural and/or pericardial effusion have been reported in individuals after sargramostim administration. Use with caution in individuals with preexisting fluid retention, pulmonary infiltrates or congestive heart failure.
Sequestration of granulocytes in the pulmonary circulation has been documented following sargramostim infusion and dyspnea has been reported occasionally in individuals treated with sargramostim. Use with caution in individuals with hypoxia or preexisting lung disease.
Occasional transient supraventricular arrhythmia has been reported in uncontrolled studies during sargramostim administration, particularly with individuals with a previous history of cardiac arrhythmia. Arrhythmias have been reversible after discontinuation of sargramostim. Use with caution in individuals with preexisting cardiac disease.
Renal and Hepatic Dysfunction
In some individuals with preexisting renal or hepatic dysfunction enrolled in uncontrolled clinical trials, administration of sargramostim has induced elevation of serum creatinine or bilirubin and hepatic enzymes. Dose reduction or interruption of sargramostim has resulted in a decrease to pretreatment levels. Monitoring of renal and hepatic function in individuals displaying renal or hepatic dysfunction prior to initiation of treatment is recommended at least every other week during sargramostim administration.
Serous allergic or anaphylactic reactions have been reported. If serious allergic or anaphylactic reaction occurs, sargramostim therapy should immediately be discontinued and appropriate therapy initiated.
A syndrome characterized by respiratory distress, hypoxia, flushing, hypotension, syncope, and/or tachycardia has been reported following the first administration of sargramostim in a particular cycle. These signs have resolved with symptomatic treatment and usually do not recur with subsequent doses in the same cycle of treatment.
Safety and effectiveness of sargramostim use in pediatric individuals have not been established; however, available safety data indicate that sargramostim does not exhibit any greater toxicity in pediatric cases than in adults.
The product information label for tbo-filgrastim (Granix, 2012) includes the following:
Splenic rupture, including fatal cases, can occur following administration of human granulocyte colony-stimulating factors. In individuals who report upper abdominal or shoulder pain after receiving tbo-filgrastim, discontinue tbo-filgrastim and evaluate for an enlarged spleen or splenic rupture.
Acute Respiratory Distress Syndrome (ARDS)
Acute respiratory distress syndrome (ARDS) can occur in individuals receiving human granulocyte colony-stimulating factors. Evaluate individuals who develop fever and lung infiltrates or respiratory distress after receiving tbo-filgrastim, for ARDS. Discontinue tbo-filgrastim in individuals with ARDS.
Serious allergic reactions including anaphylaxis can occur in individuals receiving human granulocyte colony-stimulating factors. Reactions can occur on initial exposure. The administration of antihistamines‚ steroids‚ bronchodilators‚ and/or epinephrine may reduce the severity of the reactions. Permanently discontinue tbo-filgrastim in individuals with serious allergic reactions. Do not administer tbo-filgrastim to individuals with a history of serious allergic reactions to filgrastim or pegfilgrastim.
Use in Individuals with Sickle Cell Disease
Severe and sometimes fatal sickle cell crises can occur in individuals with sickle cell disease receiving human granulocyte colony-stimulating factors. Consider the potential risks and benefits prior to the administration of human granulocyte colony-stimulating factors in individuals with sickle cell disease. Discontinue tbo-filgrastim in individuals undergoing a sickle cell crisis.
Potential for Tumor Growth Stimulatory Effects on Malignant Cells
The granulocyte colony stimulating factor (G-CSF) receptor through which tbo-filgrastim acts has been found on tumor cell lines. The possibility that tbo-filgrastim acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, diseases for which tbo-filgrastim is not approved, cannot be excluded.
The safety and effectiveness of tbo-filgrastim in children have not been established.
Absolute neutrophil count (ANC): A measure of the number of neutrophils (a type of white blood cell) in the blood.
Adjuvant or adjunctive treatment: Treatment given after the primary treatment to increase the chances of a cure and may include chemotherapy, radiation, hormone, or biological therapy.
Advanced cancer: Cancer in which the disease has spread from where it started (the primary site) to other parts of the body.
Chemotherapy: Medical treatment of a disease, particularly cancer, with drugs or other chemicals.
ECOG Performance Status: A scale used to determine the individual's level of functioning.
0= Fully active, able to carry on all pre-disease performance without restriction
1= Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2= Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3= Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4= Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair
Febrile neutropenia: Febrile neutropenia can occur as a result of severe neutropenia; defined as the occurrence of fever (greater than or equal to 38.3oC for more than 1 hour) in association with an ANC less than 0.5 x 109/L or ANC less than 1.0 x 109/L and a predicted decline to less than or equal to 0.5 x 109/L over the subsequent 48 hours.
Karnofsky Score: A measure of the individual's overall physical health, judged by their level of activity. The score is based on the following scale:
100% Normal, no complaints, no signs of disease
90% Capable of normal activity, few symptoms or signs of disease
80% Normal activity with some difficulty, some symptoms or signs
70% Caring for self, not capable of normal activity or work
60% Requiring some help; can take care of most personal requirements
50% Requires help often, requires frequent medical care
40% Disabled, requires special care and help
30% Severely disabled, hospital admission indicated but no risk of death
20% Very ill, urgently requiring admission, requires supportive measures or treatment
10% Moribund, rapidly progressive fatal disease processes
Neutropenia: A decrease in the number of neutrophils (white blood cells that respond quickly to infection) in the blood. Neutrophils less than 1,500/mm3 is considered to be neutropenic and at risk for infection. Neutrophils fewer than 500 cells/mm3 is considered at high risk of infection.
Neutrophil: A type of white blood cell that helps fight infection.
Primary prophylaxis: Prevention of febrile neutropenia with the first cycle of a specified chemotherapy regimen.
Secondary prophylaxis: Prevention of febrile neutropenia given with the second and/or subsequent cycle of a given regimen of chemotherapy for individuals who had a neutropenic complication from the preceding cycle of chemotherapy and there is no plan to reduce the dose intensity.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information|
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|01/01/2014||Updated Coding section with 01/01/2014 HCPCS changes; removed J1440, J1441 deleted 12/31/2013. Changed name of Neutroval to Granix.|
|Revised||05/09/2013||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||05/08/2013||Hematology/Oncology Subcommittee review. Clarified primary prophylaxis when FN risk is ≥ 10% and ≤ 20% based on chemotherapy regimen. Clarified ANC unit (mm3) in Filgrastim criterion I. Updated Description/Scope, Coding, Discussion, Definitions, References and Websites.|
|Revised||11/07/2012||Hematology/Oncology Subcommittee review. Added medically necessary indication for tbo-filgrastim. Updated Description/Scope, Coding, Discussion, Definitions, References and Websites.|
|Revised||05/09/2012||Hematology/Oncology Subcommittee review. Medically necessary indication for use in dose dense chemotherapy clarified, and will includes use of pegfilgrastim. Updated Discussion, References and Websites.|
|Reviewed||05/18/2011||Hematology/Oncology Subcommittee review. Updated Discussion, Coding, References and Websites.|
|Revised||05/12/2010||Hematology/Oncology Subcommittee review. Reformatted clinical indications. Restated medically necessary indication for prophylaxis of febrile neutropenia (FN). Deleted redundant not medically necessary FN indications. Added not medically necessary indication "For uses not meeting the above criteria." Updated Rationale, References and Websites.|
|Revised||05/20/2009||Hematology/Oncology Subcommittee review. Deleted Place of Service section. Dosing table removed. Deletion of medically necessary indications for malignant melanoma, neonatal sepsis in infants with pre-eclampsia-associated neutropenia, and drug induced agranulocytosis. Added medically necessary indication for glycogen storage disease, hairy cell leukemia. Coding updated.|
|10/01/2008||Updated coding section with 10/01/2008 ICD-9 changes.|
|Reviewed||05/14/2008||Hematology/Oncology Subcommittee review. Format changed to align indications with specific agents. Updated the off-label indications for filgrastim and sargramostim. Clarified the FDA labeled indications for sargramostim.|
|Revised||05/16/2007||Hematology/Oncology Subcommittee review. Title changed from CSF to White Blood Cell Growth Factors. Removed clinical protocols information from Pediatric indications. Modified medical necessity statement for non-oncologic label and off-label indications. Dosing, references and coding updated.|
|New||06/08/2006||MPTAC. New Guideline including 2006 American Society of Clinical Oncology (ASCO) Updated recommendations.|
|New||06/07/2006||Hematology/Oncology Subcommittee. New Guideline.|
Last Review Date
|WellPoint Health Networks, Inc.|
|Pharmacology Toolkit||Filgrastim (Neupogen®, G-CSF)|
|Pharmacology Toolkit||Neulasta® (Pegfilgrastim)|
|Pharmacology Toolkit||Sargramostim (Leukine®, Prokine®)|