Policy
Tecentriq^™ (atezolizumab) is considered MEDICALLY NECESSARY for members with locally advanced or metatstatic urothelial carcinoma who meet at least one of the two following criteria:

• Have disease progression during or following platinum-containing chemotherapy 

• Are not eligible for cisplatin-containing chemotherapy  

Tecentriq™ (atezolizumab) is considered MEDICALLY NECESSARY for members with metastatic non-small cell lung cancer who meet at least one of the following criteria: 

• Adjuvant treatment (as a single agent) following resection and platinum-based chemotherapy in adults with stage II to IIIA non–small cell lung cancer (NSCLC) whose tumors have PD-L1 expression on ≥ 1% of tumor cells, as determined by an approved test.

• First-line treatment (single agent) of metastatic NSCLC in adults whose tumors have high PD-L1 expression (PD-L1 stained ≥ 50% of tumor cells [TC ≥ 50%] or PD-L1 stained tumor-infiltrating IC covering ≥ 10%), as determined by an approved test, with no epidermal growth factor receptor (EGFR) or ALK genomic tumor aberrations.

• First-line treatment (in combination with bevacizumab, paclitaxel, and carboplatin) of metastatic nonsquamous NSCLC in adults with no EGFR or ALK genomic tumor aberrations.

• First-line treatment (in combination with paclitaxel [protein bound] and carboplatin) of metastatic nonsquamous NSCLC in adults with no EGFR or ALK genomic tumor aberrations.

• Treatment (single agent) of metastatic NSCLC in adults with disease progression during or following platinum-containing chemotherapy (patients with EGFR or ALK genomic aberrations should have disease progression on approved therapy for EGFR or ALK genomic tumor mutations prior to receiving atezolizumab).

Tecentriq™ is considered MEDICALLY NECESSARY in combination with paclitaxel protein-bound for the treatment of adult patients with unresectable locally advanced or metastatic TNBC whose tumors express PD-L1 (PD-L1 stained tumor-infiltrating immune cells (IC) of any intensity covering > 1% of the tumor area), as determined by an FDA-approved test. 

Tecentriq™ is considered MEDICALLY NECESSARY in combination with carboplatin and etoposide, for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC).

Tecentriq™ is considered MEDICALLY NECESSARY in treatment of unresectable or metastatic hepatocellular carcinoma (in combination with bevacizumab) in patients who have not received prior systemic therapy.

Tecentriq™ is considered MEDICALLY NECESSARY in treatment of BRAF V600 mutation-positive unresectable or metastatic melanoma (in combination with cobimetinib and vemurafenib). 

Dosage 

• Administer 1,200 mg as an intravenous infusion over 60 minutes every 3 weeks. (2.1)

• Dilute prior to intravenous infusion. (2.3) 

Injection: 1,200 mg/20 mL (60 mg/mL) solution in a single-dose vial (3)

Use of Tecentriq^™ for any use other than described above is considered INVESTIGATIONAL.

References 

1. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm501762.htm.  FDA approves new, targeted treatment for bladder cancer.

2. http://www.gene.com/media/press-releases/14621/2016-03-14/fda-grants-genentechs-cancer-immunothera. FDA Grants Genentech’s Cancer Immunotherapy Atezolizumab Priority Review for Advanced Bladder Cancer.

3. Atezolizumab (Tecentriq™) prescribing information, 2016 available at: http://www.gene.com/download/pdf/tecentriq_prescribing.pdf

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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