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Bevacizumab-awwb injection, for Intravenous Use (Mvasi™) HCPCS Code Q5107 - Injection, Bevacizumab, (Mvasi™), 10 mg: Billing Guidelines

Tuesday, October 1, 2019

Effective with date of service July 22, 2019, the North Carolina Medicaid and NC Health Choice programs cover bevacizumab-awwb injection, for intravenous use (Mvasi™) for adult use in the Physician Administered Drug Program when billed with HCPCS code Q5107 - Injection, bevacizumab, (Mvasi™), 10 mg.

Strength/Package Size(s):  Injection: 100 mg/4 mL (25 mg/mL) in a single-dose vial

Injection: 400 mg/16 mL (25 mg/mL) in a single-dose vial

Indicated for the treatment of:

  • Metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment.
  • Metastatic colorectal cancer, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line bevacizumab product-containing regimen. (Mvasi is not indicated for adjuvant treatment of colon cancer).
  • Unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer, in combination with carboplatin and paclitaxel for first-line treatment.
  • Recurrent glioblastoma in adults.
  • Metastatic renal cell carcinoma in combination with interferon-alfa.
  • Persistent, recurrent, or metastatic cervical cancer, in combination with paclitaxel and cisplatin, or paclitaxel and topotecan.

Recommended Dose:  Metastatic colorectal cancer:

  • 5 mg/kg every 2 weeks with bolus-IFL
  • 10 mg/kg every 2 weeks with FOLFOX4
  • 5 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin based chemotherapy after progression on a first-line bevacizumab product-containing regimen

First-line non-squamous non-small cell lung cancer:

  • 15 mg/kg every 3 weeks with carboplatin and paclitaxel

Recurrent glioblastoma:

  • 10 mg/kg every 2 weeks

Metastatic renal cell carcinoma:

  • 10 mg/kg every 2 weeks with interferon-alfa

Persistent, recurrent, or metastatic cervical cancer:

  • 15 mg/kg every 3 weeks with paclitaxel and cisplatin or paclitaxel and topotecan

See full prescribing information for further detail.

For Medicaid and NC Health Choice Billing

The ICD-10-CM diagnosis code(s) required for billing is/are: 

Metastatic colorectal cancer:

C18.0 - Malignant neoplasm of the cecum; C18.1 - Malignant neoplasm of appendix; C18.2 - Malignant neoplasm of ascending colon; C18.3 - Malignant neoplasm of hepatic flexure; C18.4 - Malignant neoplasm of transverse colon; C18.5 - Malignant neoplasm of splenic flexure; C18.6 - Malignant neoplasm of descending colon; C18.7 - Malignant neoplasm of sigmoid colon; C18.8 - Malignant neoplasm of overlapping sites of colon; C18.9 - Malignant neoplasm of colon, unspecified; C19 - Malignant neoplasm of rectosigmoid junction; C20 - Malignant neoplasm of rectum; C21.8 - Malignant neoplasm of overlapping sites of rectum, anus and anal canal;

Unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer:

C33- Malignant neoplasm of trachea; C34.00 - Malignant neoplasm of unspecified main bronchus; C34.01 - Malignant neoplasm of right main bronchus; C34.02 - Malignant neoplasm of left main bronchus; C34.10 - Malignant neoplasm of upper lobe, unspecified bronchus or lung; C34.11 - Malignant neoplasm of upper lobe, right bronchus or lung; C34.12 - Malignant neoplasm of upper lobe, left bronchus or lung; C34.2 Malignant neoplasm of middle lobe, bronchus or lung; C34.30 - Malignant neoplasm of lower lobe, unspecified bronchus or lung; C34.31 - Malignant neoplasm of lower lobe, right bronchus or lung; C34.32 - Malignant neoplasm of lower lobe, left bronchus or lung; C34.80 - Malignant neoplasm of overlapping sites of unspecified bronchus and lung; C34.81 - Malignant neoplasm of overlapping sites of right bronchus and lung; C34.82 - Malignant neoplasm of overlapping sites of left bronchus and lung; C34.90 - Malignant neoplasm of unspecified part of unspecified bronchus or lung; C34.91 - Malignant neoplasm of unspecified part of right bronchus or lung; C34.92 - Malignant neoplasm of unspecified part of left bronchus or lung;

Recurrent glioblastoma:

C71.0 - Malignant neoplasm of cerebrum, except lobes and ventricles; C71.1 - Malignant neoplasm of frontal lobe; C71.2 - Malignant neoplasm of temporal lobe; C71.3 - Malignant neoplasm of parietal lobe; C71.4 - Malignant neoplasm of occipital lobe; C71.5 - Malignant neoplasm of cerebral ventricle; C71.6 - Malignant neoplasm of cerebellum; C71.7 - Malignant neoplasm of brain stem; C71.8 - Malignant neoplasm of overlapping sites of brain; C71.9 - Malignant neoplasm of brain, unspecified;

Metastatic renal cell carcinoma:

C64.1 - Malignant neoplasm of right kidney, except renal pelvis; C64.2 - Malignant neoplasm of left kidney, except renal pelvis; C64.9 - Malignant neoplasm of unspecified kidney, except renal pelvis;C65.1 - Malignant neoplasm of right renal pelvis; C65.2 - Malignant neoplasm of left renal pelvis; C65.9 - Malignant neoplasm of unspecified renal pelvis

Persistent, recurrent, or metastatic cervical cancer:

C53.0 - Malignant neoplasm of endocervix; C53.1 - Malignant neoplasm of exocervix; C53.8 - Malignant neoplasm of overlapping sites of cervix uteri; C53.9 - Malignant neoplasm of cervix uteri, unspecified;

  • Providers must bill with HCPCS code:  Q5107 - Injection, bevacizumab, (Mvasi), 10 mg
  • One Medicaid and NC Health Choice unit of coverage is:  10 mg The maximum reimbursement rate per unit is:  $73.16
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units.  The NDCs is/are: 55513-0206-01, 55513-0207-01
  • The NDC units should be reported as "UN1".
  • For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
  • For additional information regarding NDC claim requirements related to the PADP, refer to the PADP, Attachment A, H.7 on DHB's website.
  • Providers shall bill their usual and customary charge for non-340B drugs.
  • PADP reimburses for drugs billed for Medicaid and NC Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the "UD" modifier on the drug detail.

The fee schedule for the PADP is available on NC Medicaid's PADP web page.

Author: 
GDIT, (800) 688-6696