![]() For use in combination with irreversible electroporation for the treatment of prostate cancer bone metastasis.For use in combination with docetaxel or any other chemotherapy.For use in combination with bortezomib for the treatment of multiple myeloma.Bone metastasis from breast cancer, kidney cancer, lung cancer and paraganglioma.Source: Bayer Healthcare, 2019 Experimental and InvestigationalĪetna considers more than one course (total of 6 injections) of radium Ra 223 dichloride (Xofigo) experimental and investigational because the safety and efficacy of more than one course has not been established.Īetna considers the use of radium Ra 223 dichloride (Xofigo) experimental and investigational for the following indications (not an all-inclusive list) because its effectiveness for these indications have not been established: See Full Prescribing Information for calculation of volume to be administered (mL). Note: Safety and efficacy beyond 6 injections with Xofigo have not been studied. Xofigo is to be administered by slow intravenous injection over 1 minute. The recommended dose regimen of Xofigo is 55 kBq (1.49 microcurie) per kg body weight, given at 4-week intervals for 6 injections. ![]() Xofigo (radium Ra 223 dichloride) is available as a single-dose vial at a concentration of 1,100 kBq/mL (30 microcurie/mL) at the reference date with a total radioactivity of 6,600 kBq/vial (178 microcurie/vial) at the reference date. CPB 0361 - Radiopharmaceuticals Strontium-89 (Metastron) and Samarium-153 (Quadramet) for Bone Pain.See Dosage and Administration information. The member does not have visceral metastatic disease.Īetna considers all other indications as experimental and investigational (for additional information, see Experimental and Investigational and Background sections).The member has symptomatic bone metastases and.Criteria for Initial Approval Prostate CancerĪetna considers one course (a total of 6 injections of radium Ra 223 dichloride (Xofigo) medically necessary for treatment of bone metastases for members with castration-resistant prostate cancer when both of the following criteria are met:.Precertification of radium Ra 223 dichloride (Xofigo) is required of all Aetna participating providers and members in applicable plan designs. Number: 0874 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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