Background

Kimmtrak is a medication used to treat a specific type of eye cancer called uveal melanoma. It is a bispecific protein that helps the body's immune system attack cancer cells. Specifically, it is used for patients with HLA-A*02:01-positive unresectable or metastatic uveal melanoma.

Policy (Criteria)

Kimmtrak (tebentafusp) is considered MEDICALLY NECESSARY when the following criteria are met:

1. 1. Provider attestation that patient has HLA-A*02:01-positive uveal melanoma, AND
   2. Disease is unresectable or metastatic, AND
   3. Being used as single agent therapy

Approval duration: 6 months

Continuation of Kimmtrak is considered MEDICALLY NECESSARY when there is documentation that member is responsive to therapy with no disease progression.

Approval duration: 12 months

Covered Doses

Dose maximum of 20 mcg IV on Day 1, 30 mcg IV on Day 8, 68 mcg IV on Day 15, and 68 mcg IV once every week thereafter.

References

1. AHFS®. Available by subscription at http://www.lexi.com
2. DrugDex®. Available by subscription at http://www.micromedexsolutions.com
3. Kimmtrak® (tebentafusp-tebn) [Prescribing Information]. Conshohocken, PA: Immunocore Commercial LLC.; 1/2022.
4. National Comprehensive Cancer Network. Melanoma: Uveal (Version 2.2022). Available at: www.nccn.org/
5. Kimmtrak® Billing and Code Guide. Available at https://kimmtrakhcp.com/pdf/KIMMTRAK-billing-and-coding-guide.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, technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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