Oxford Health Plans > Providers' Tools & Resources > Oncology Resource Center > National Comprehensive Cancer Network (NCCN) Compendium

NATIONAL COMPREHENSIVE CANCER NETWORK (NCCN) COMPENDIUM
Clinical Practice Guidelines in Oncology

NCCN Drugs & Biologics Compendium

NCCN Categories of Evidence and Consensus

Oxford Medical Policy: Chemotherapy Drugs/Application of NCCN Clinical Practice Guidelines


NCCN Drugs & Biologics Compendium

Effective May 1, 2008, Oxford will use the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium, in reviewing requests for coverage for chemotherapy drugs administered in an outpatient setting. The NCCN Compendium provides an independent, respected resource for use in making chemotherapy coverage decisions and it is readily available to physicians and their patients at www.nccn.org.

  • The Compendium, derived from the Clinical Practice Guidelines in Oncology, is compiled by oncology panels from academic cancer centers. It is a widely acknowledged national, independent resource of information that is recognized as the standard of care for oncology in the United States.

  • The Compendium lists the appropriate drugs and biologics for specific cancers using US Food and Drug Administration (FDA) approved disease indications and specific NCCN panel recommendations. Each recommendation is supported by a level of evidence category.

  • NCCN updates their Compendium on a monthly basis. New drugs and/or indications for a drug will not be eligible for reimbursement until a recommendation of 1, 2A or 2B is listed in the Compendium.


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NCCN Categories of Evidence and Consensus

The National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium lists appropriate uses of agents for each specific cancer derived from the Clinical Practice Guidelines in Oncology.

  • The treatment recommendations are based on a consensus of expert opinion.

  • The recommendations are categorized using grades that describe the type of evidence available and the degree of consensus among panel members. The NCCN Categories of Evidence and Consensus are defined below.

  • If the NCCN Compendium lists the drug with a recommendation level 1, 2A or 2B for the condition, the service is eligible for reimbursement based on the member's coverage documents. In general, we do not cover chemotherapy drugs with only level 3 recommendations. However, coverage determinations for chemotherapy drugs with only level 3 recommendations will be reviewed pursuant to Oxford's Medical Necessity and Experimental/Investigational Treatment policies.

    Category of Evidence and Consensus Quality of Evidence Level of Consensus
    1 High Uniform
    2A Lower Uniform
    2B Lower Non-uniform
    3 Any Major disagreement

    • Category 1: The recommendation is based on high-level evidence (i.e., high-powered randomized clinical trials or meta-analyses), and the panel has reached uniform consensus that the recommendation is indicated. In this context, uniform means near unanimous positive support with some possible neutral positions.

    • Category 2A: The recommendation is based on lower level evidence, but despite the absence of higher level studies, there is uniform consensus that the recommendation is appropriate.

    • Category 2B: The recommendation is based on lower level evidence, and there is non-uniform consensus that the recommendation should be made. In these instances, because the evidence is not conclusive, institutions take different approaches to the management of a particular clinical scenario. This non-uniform consensus does not represent a major disagreement; rather it recognizes that given imperfect information, institutions may adopt different approaches.

    • Category 3: There is major disagreement among the panel members about the significance of the clinical trials. Panel members are not able to reach an agreement about the effectiveness of the drug for this diagnosis. The category 3 designation alerts clinicians to a major interpretation issue in the data and an explanation is provided in the guidelines. These drug/diagnosis combinations will be reviewed by our medical review team and if services are determined to be ineligible for coverage, they will be denied as not medically necessary or experimental/investigational.

    A more detailed description of the treatment recommendations may be viewed at www.nccn.org.

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Oxford Medical Policies:

Oxford's medical policies outlining the coverage criteria for chemotherapy drugs administered in an outpatient setting (per the NCCN clinical practice guidelines) may be viewed on www.oxfordhealth.com under:

Please note the following:

  • This policy provides parameters for coverage of injectable oncology medications covered under the medical benefit based upon the NCCN Drugs & Biologics Compendium. The Compendium lists the appropriate drugs and biologics for specific cancers using US Food and Drug Administration (FDA) approved disease indications and specific NCCN panel recommendations. Each recommendation is supported by a level of evidence category.

  • This policy and parameters for coverage do NOT apply to ancillary medications that are given with oncology therapies. These include, but are not limited to antimicrobials, pain medications, anti-emetics, hormones, erythropoietin products, immune globulin products, bisphonates, anxiolytics, and antisychotics.

  • Drugs and/or diagnosis that are not listed on the NCCN Compendium will require additional review of the claim to determine if services are eligible for reimbursement.

  • This policy requires that the physician/facility always include the primary cancer diagnosis on the claim.

    • Claims submitted with only a V58.1 (maintenance chemotherapy) diagnosis code may require additional information prior to a coverage decision.

  • If the NCCN Compendium lists the drug with a recommendation level 1, 2A or 2B for the condition, the service is eligible for reimbursement based on the member's coverage documents. In general, we do not cover chemotherapy drugs with only level 3 recommendations. However, coverage determinations for chemotherapy drugs with only level 3 recommendations will be reviewed pursuant to Oxford's Medical Necessity and Experimental/Investigational Treatment policies.

  • Physicians/facilities or Members may elect to have a chemotherapy drug administered in an outpatient setting reviewed on either a pre-service or post-service basis:

    • If a drug has a recommendation level of 1, 2A, or 2B pursuant to NCCN guidelines for a particular condition, the corresponding claim will be reimbursed in accordance with the member's health benefit plan.

    • If a drug does not have a recommendation level of 1, 2A, or 2B, the corresponding claim will be reviewed by an Oxford medical director pursuant to our Medical Necessity and/or Experimental/Investigational Treatment policies.

  • This policy was applied to all Commercial benefit plans administered by Oxford on May 1, 2008. Note: This policy was implemented for benefit plans administered by UnitedHealthcare on March 15, 2008.

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