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Kymriah (Tisagenlecleucel) Kymriah (tisagenlecleucel) Policy Number: Current Effective Date: MM.02.036 August 1, 2019 Lines of Business: Original Effective Date: HMO; PPO; QUEST Integration June 1, 2018 Precertification: Place(s) of Service: Required, see section IV Inpatient I. Description The spontaneous regression of certain cancers (e.g., renal cell carcinoma, melanoma) supports the idea that a patient’s immune system can delay tumor progression and, on rare occasions, can eliminate tumors altogether. These observations have led to research into various immunologic therapies designed to stimulate a patient’s own immune system. Adoptive immunotherapy is a method of activating lymphocytes and/or other types of cells for the treatment of cancer and other diseases. Cells are removed from the patient, processed for some period of time, and then infused back into the patient. Tisagenlecleucel For individuals who are 3 to 25 years of age with relapsed or refractory B-cell acute lymphoblastic leukemia who receive tisagenlecleucel, the evidence includes multiple single-arm prospective trials. Relevant outcomes are overall survival, disease-specific survival, quality of life, and treatment-related mortality and morbidity. The pivotal single-arm trials reported an 83% response rate (measured by complete response or complete remission with incomplete blood count) in heavily pretreated patients. All patients who achieved a complete remission or complete remission with incomplete blood count were also minimal residual disease- negative, which is predictive of survival in acute lymphoblastic leukemia patients. After a median follow-up of 4.8 months, the median duration of response was not reached. The observed benefits seen with tisagenlecleucel were offset by a high frequency and severity of adverse reactions. Cytokine release syndrome was observed in more than half (63%) of the patients, and approximately 40% had an adverse event at grade 4 or higher. Long-term follow-up and real-world evidence is required to assess the generalizability of tisagenlecleucel efficacy and safety outside of a clinical trial setting. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. II. Policy Criteria A. Tisagenlecleucel intravenous infusion is considered medically necessary for patients with refractory or second relapse B-Cell precursor acute lymphoblastic leukemia (ALL) if they meet all of the following criteria: 1. Patient has been diagnosed with relapseda/refractoryb B-Cell precursor acute lymphoblastic leukemia; and 2. Patient is 25 years old or younger at the time of infusion; and 3. The patient has a confirmed CD19 tumor expression; and 4. Have not received prior treatment with tisagenlecleucel or any other gene therapy or are being considered for treatment with any other gene therapy; and Kymriah (tisagenlecleucel) II-2 5. If the patient has Philadelphia chromosome positive (Ph+) ALL, they have tried and failed, is intolerant to, or has a contraindication to at least 2 tyrosine kinase inhibitors (TKI); and 6. The patient will not be treated with more than 2.5 x 108 CAR-positive viable T cells; and 7. If the patient is 50kg or less in weight, they will receive weight-based dosing at 0.2 to 5.0 x 106 CAR- positive viable T cells per kg of body weight; and 8. The patient has received or will receive lymphodepleting chemotherapy [fludarabine (30 mg/m2 intravenous daily for 4 days) and cyclophosphamide (500 mg/m2 intravenous daily for 2 days starting with the first dose of fludarabine)] within two weeks preceding tisagenlecleucel (Kymriah) infusion; and 9. The patient has been treated with 2 cycles of standard chemotherapy without a complete response or achieved a complete response and experienced multiple relapses following standard chemotherapy (at least 2 cycles); and 10. The patient does not have active central nervous system (CNS) malignancy involvement (i.e. white blood cell (WBC) count greater than or equal to 5 cells/mcl in the cerebral spinal fluid (CSF) with presence of lymphoblasts); and 11. The patient has adequate organ function with no significant deterioration in organ function expected within 4 weeks after apheresis; and 12. The patient does not have any of the following: a. Burkitt lymphoma b.Active hepatitis B, C, or any uncontrolled infection c. Grade 2 to 4 graft-versus-host disease d.Concomitant genetic syndrome with the exception of Down syndrome e. Received allogeneic cellular therapy, such as donor lymphocyte infusion, within 6 weeks prior to tisagenlecleucel infusion f. Patient has active central nervous system 2 or 3 acute lymphoblastic leukemia (ie, white blood cell count ≥5 cells/μL in cerebrospinal fluid with presence of lymphoblasts); and 13. The prescriber will submit documentation of response to tisagenlecleucel (Kymriah) within 3 months following therapy as a follow-up to the prior approval request. B. Tisagenlecleucel intravenous infusion is considered medically necessary for patients with relapsed or refractory B-cell lymphoma if they meet all of the following criteria: 1. Patient has been diagnosed with relapseda/refractoryb B-Cell lymphoma including any of the following; a. Diffuse large B-cell lymphoma (DLBCL) not otherwise specified; OR b.High grade B-cell lymphoma; OR c. Diffuse large B-cell lymphoma (DLBCL) arising from follicular lymphoma; AND 2. Patient is 18 years of age or older; and 3. Have not received prior treatment with tisagenlecleucel or any other gene therapy or are being considered for treatment with any other gene therapy; and 4. The patient has experienced disease progression following a trial of two or more lines of systemic therapy; and 5. Previous therapy included anthracycline chemotherapy agent and an anti-CD20 antibody; and 6. The patient will not be treated with more than 2 x 108 CAR-postive viable T cells; and 7. The patient will be treated within a dosage range of 0.6 to 6.0 x 108 CAR-positive viable T cells suspended in one or more patient specific infusion bag(s) for i.v. infusion; and 8. If the patient is under 100kg in weight, they will receive weight-based dosing 2 x 106 CAR-positive viable T cells per kg of body weight; and 9. The patient has received or will receive lymphodepleting chemotherapy: Fludarabine (25 mg/m2 i.v. daily for 3 days) and cyclophosphamide (250 mg/m2 IV daily for 3 days starting with the first dose of Kymriah (tisagenlecleucel) IV-3 fludarabine) OR alternate therapy with bendamustine 90 mg/m2 intravenous daily for 2 days for patients unable to receive cyclophosphamide] within two weeks preceding Kymriah infusion, OR the patient is unable to receive lymphodepleting chemotherapy if WBC count is less than or equal to 1x109/L within one week prior to Kymriah infusion; and 10. The patient does not have primary central nervous system (CNS) lymphoma; and 11. The patient does not have any of the following: a. Human immunodeficiency virus (HIV) b.Active Hepatitis B or C, or c. Any autoimmune disease requiring immune suppression. a Relapsed disease describes the reappearance of leukemia cells in the bone marrow or peripheral blood after the attainment of a complete remission with chemotherapy and/or allogeneic cell transplant. b Refractory (resistant) disease is defined as those patients who fail to obtain complete response with induction therapy, ie, failure to eradicate all detectable leukemia cells (<5% blasts) from the bone marrow and blood with subsequent restoration of normal hematopoiesis (>25% marrow cellularity and normal peripheral blood counts). III. Limitations Tisagenlecleucel is not covered for all other indications not listed above. IV. Administrative Guidelines A. Precertification is required. To pre-certify, complete HMSA’s Precertification Request form and fax or mail the form, or use iExchange with the following documentation: 1. Clinical Notes of past and current treatment 2. Confirmation of Diagnosis (e.g. imaging, path) 3. Recent Labs A. Autologous lymphocytes used as part of adoptive immunotherapy may be harvested in a pheresis procedure or may be isolated from resected tumor tissue. B. The recommended dosage of tisagenlecleucel for patients 50 kg or less is 0.2 to 5.0×106 chimeric antigen receptor-positive viable T cells per kg body weight intravenously; for patients above 50 kg, dose is 0.1 to 2.5 x 108 total chimeric antigen receptor-positive viable T cells (non-weight-based) intravenously. C. Central nervous system (CNS) disease for B-cell acute lymphoblastic leukemia is defined by the following groups: 1. CNS 1: Absence of blasts on cerebrospinal fluid cytospin preparation, regardless of the white blood cell (WBC) count 2. CNS 2: WBC count of less than 5/mL and blasts on cytospin findings 3. CNS 3: WBC count of 5/mL or more and blasts on cytospin findings and/or clinical signs of CNS leukemia (eg, facial nerve palsy, brain/eye involvement, hypothalamic syndrome) D. Tisagenlecleucel has a black box warning because of the risk of cytokine release syndrome and neurologic toxicities that include fatal or life-threatening reactions. It should not be administered to patients with active infection or inflammatory disorders. It is recommended that severe or life- threatening cytokine release syndrome should be treated with tocilizumab. Patients should be monitored for neurologic events after treatment. E. Tisagenlecleucel is available only through a restricted program under a risk evaluation and mitigation strategy (REMS) called the Kymriah REMS. The requirement for the REMS components are as follows: Kymriah (tisagenlecleucel) V-4 1. Health care facilities that dispense and administer tisagenlecleucel must be enrolled and comply with the REMS requirements. 2. Certified health care facilities must have onsite, immediate access to tocilizumab, and ensure that a minimum of 2 doses of tocilizumab are available for each patient for administration within 2 hours after tisagenlecleucel infusion, if needed for treatment of cytokine release syndrome. 3. Certified health care facilities must ensure that health care providers who prescribe, dispense or administer tisagenlecleucel are trained about the management of cytokine release syndrome and neurologic toxicities.
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