BlueCross BlueShield of Tennessee Medical Policy Manual

Temsirolimus (Torisel®)

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the medical policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.

POLICY

I.      INDICATIONS

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

A.    FDA-Approved Indication

Advanced renal cell carcinoma (RCC)

B.    Compendial Uses

1.     Relapsed or stage IV renal cell carcinoma

2.     Endometrial carcinoma

3.     Soft tissue sarcoma subtypes:

a.     Perivascular epithelioid cell tumors (PEComa)

b.     Rhabdomyosarcoma

c.     Angiomyolipoma

d.     Lymphangioleiomyomatosis

4.     Mantle cell lymphoma (MCL)

5.     Uterine Sarcoma

All other indications are considered experimental/investigational and not medically necessary.

II.     CRITERIA FOR INITIAL APPROVAL

A.    Renal Cell Carcinoma

Authorization of 12 months may be granted as a single agent for treatment of advanced, relapsed, or stage IV renal cell carcinoma.

B.    Endometrial Carcinoma

Authorization of 12 months may be granted as a single agent for subsequent treatment of recurrent endometrial carcinoma.

C.    Soft Tissue Sarcoma

1.     Authorization of 12 months may be granted for treatment of any of the following subtypes of soft tissue sarcoma as single agent therapy: locally advanced unresectable or metastatic perivascular epithelioid cell tumor (PEComa), recurrent angiomyolipoma, or recurrent lymphangioleiomyomatosis.

2.     Authorization of 12 months may be granted for treatment of rhabdomyosarcoma in combination with cyclophosphamide and vinorelbine.

D.    Mantle Cell Lymphoma

Authorization of 12 months may be granted for treatment of relapsed or refractory mantle cell lymphoma.

E.    Uterine Sarcoma

Authorization of 12 months may be granted as a single agent for subsequent treatment of advanced, recurrent/metastatic or inoperable PEComa.

III.   CONTINUATION OF THERAPY  

Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in Section II when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

ADDITIONAL INFORMATION  

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

REFERENCES

1. Torisel [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals Inc.; April 2023.
2. The NCCN Drugs & Biologics Compendium^® © 2024 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed May 10, 2024. 
3. Clinical Pharmacology. Elsevier Inc. Available at: https://www.clinicalkey.com/pharmacology/. Accessed May 10, 2024.
4. Hess G, Herbrecht R, Romaguerra J, et al. Phase III study to evaluate temsirolimus compared with investigator’s choice therapy for the treatment of relapsed or refractory mantle cell lymphoma. J Clin Oncol. 2009;27:3822-29.

ORIGINAL EFFECTIVE DATE: 12/1/2016

MOST RECENT REVIEW DATE: 12/10/2024

ID_CHS

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.