Oral Anticancer Drugs - Policy Article - Effective June 20… · Oral anticancer drugs which are...

Article for Oral Anticancer Drugs - Policy Article - Effective June 2010 (August 2010 Revision) (A25619) This Article will be updated in the Medicare Coverage Database on August 19, 2010.

Contractor Information

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CIGNA Government Services

Contractor Number back to top

18003

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DME MAC

Article Information

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A25619

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Article

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Yes

Article Title back to top

Oral Anticancer Drugs - Policy Article - Effective June 2010 (August 2010 Revision)

AMA CPT / ADA CDT Copyright Statement back to top

CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico South Carolina Tennessee Texas Virginia Virgin Islands West Virginia

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Jurisdiction C

Original Article Effective Date back to top

04/01/2005

Article Revision Effective Date back to top

06/01/2010

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NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as non-covered. Oral Anticancer Drugs For an oral anticancer drug to be covered, all of the following

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criteria (1-4) must be met:

1. It is a drug or biological that has been approved by the Food and Drug Administration (FDA), and

2. It has the same active ingredients as a non-self-administrable anticancer chemotherapeutic drug or biological that is covered when furnished incident to a physician's service. The oral anticancer drug and the non-self-administrable drug must have the same chemical/generic name as indicated by the FDA's Approved Drug Products (Orange Book), Physician's Desk Reference (PDR), or an authoritative drug compendium, or it is a prodrug which, when ingested, is metabolized into the same active ingredient which is found in the non-self-administrable form of the drug, and

3. It is used for the same anticancer chemotherapeutic indications, including unlabeled or “off’label” uses, as the non-self-administrable form of the drug, and

4. It is prescribed by a physician or other practitioner licensed under state law to prescribe such drugs as anticancer chemotherapeutic agents.

A drug that is not available in an injectable form does not meet criterion 2. If an oral anticancer drug is used for immunosuppression (rather than the treatment of cancer), criterion 3 is not met, and the drug cannot be covered under the oral anticancer drug benefit. (If the drug is used for immunosuppression following organ transplant, refer to the Immunosuppressive Drugs policy.) If criteria 1-4 are not met, the drug will be denied as non-covered. A claim denied for the reason that a diagnosis does not fall in the section below in this Policy Article titled “ICD-9 Codes that are Covered” will receive a statutory denial as non-covered, but may be covered at appeal if and only if it can be shown to be allowed under CMS IOM 100-02, Chapter 15, Section 50 – Drugs and Biologicals, and under the Social Security Act, Sec.1861(s)(Q).

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The quantity of oral anticancer drugs that is dispensed should be limited to a 30-day supply. Prescriptions may be refillable. Antiemetic Drugs Used With Oral Anticancer Drugs A self-administered antiemetic drug billed with code J8498 or J8597 is covered if all of the following criteria are met:

1. It is used in conjunction with a covered oral anticancer drug, and

2. It is likely that administration of the covered oral anticancer drug will induce emesis if the antiemetic drug is not administered, and

3. The antiemetic drug is administered within 2 hours before the covered oral anticancer drug is administered.

Antiemetic drugs are covered under the oral anticancer drug benefit for the sole purpose of allowing the absorption of the covered oral anticancer drug. Therefore, coverage is limited to doses of antiemetic drugs, which are administered during the two hours before administration of the covered oral anticancer drug. Doses of antiemetic drugs administered after the administration of the oral anticancer drug (e.g., to treat nausea or vomiting which is caused by the oral anticancer drug or other etiology) are non-covered. If all of the criteria are not met, the antiemetic drug will be denied as non-covered. For information on the coverage of oral antiemetic drugs when they are used as a full replacement for intravenous antiemetic drugs used in conjunction with intravenous cancer chemotherapeutic regimens, refer to the Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) policy. Supply Fee One unit of service of supply fee code Q0511 is covered for the first covered oral anticancer drug that is dispensed in a 30-day period. If covered drugs are dispensed by more than one

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pharmacy during a 30-day period, one unit of Q0511 is covered for each pharmacy. One unit of service of supply fee code Q0512 is covered for each subsequent covered oral anticancer drug that is dispensed in that 30-day period. If two dosage strengths of the same drug are dispensed on the same day, one unit of service of the appropriate supply fee is payable for each one. If more than one unit of service of code Q0511 is billed per 30 days by a single pharmacy, the excess units of service will be paid comparable to code Q0512. If the billed units of service of Q0511 or Q0512 exceed the number of drugs on the claim, the excess units will be denied as not separately payable. Supply fees are eligible for coverage only for drugs that are covered under this LCD. If the drug on the claim is denied as non-covered, the supply fee will be denied as non-covered. The supply fee code must be billed on the same claim as the drug(s). If it is not, the supply fee will be denied as incorrect billing. J8498 is not eligible for payment of a supply fee. CODING GUIDELINES For the instructions below that apply to J codes, when claims are billed in NCPDP format using NDC numbers, different instructions may apply. Refer to the NCPDP Companion Document available through the CMS web site. The National Drug Code (NDC) is a number, which uniquely identifies a manufacturer's product in terms of the strength of each tablet/capsule, quantity of tablets/capsules in a package, and other packaging details. Suppliers must use the NDC that matches the product dispensed. For all NDC numbers, 1 unit of service = 1 tablet or 1 capsule. For codes J8498 and J8597, 1 unit of service = 1 mg. National Drugs Codes (NDCs) may be billed only when the drug is used as an oral anticancer drug. If cyclophosphamide or

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methotrexate are prescribed as an oral immunosuppressive drug following an organ transplant, code J8530 or J8610 respectively must be used. (Refer to the Immunosuppressive Drugs policy for additional information.) If, for example, cyclophosphamide or methotrexate is prescribed as an oral immunosuppressive drug for other conditions (e.g., lupus, rheumatoid arthritis, etc.), a claim should not be submitted to Medicare (unless requested by the beneficiary; and in which case it would be submitted with a GY modifier) because there is no statutory benefit for oral immunosuppressive drugs in these conditions. Code J8498 or J8597 may be billed only when the antiemetic drug is used in conjunction with a covered oral anticancer drug. Suppliers may bill only for quantities of antiemetic drugs that are to be used within 2 hours before the covered oral anticancer drug. Refer to the Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) policy for information on billing oral antiemetics used in conjunction with intravenous cancer chemotherapeutic regimens. A list of valid NDC numbers for covered oral anticancer drugs can be found on the Pricing, Data Analysis and Coding (PDAC) Contractor web site. Until a new NDC number is added to the list, suppliers must submit claims using code J8999. Oral anticancer drugs which are not covered under the oral anticancer drug benefit (i.e., those that are not specifically listed in this policy) must be billed using code A9270 (noncovered item or service) if the supplier chooses to submit a claim. Suppliers should contact the PDAC for guidance on the correct coding of these items.

Coding Information

ICD-9 Codes that are Covered back to top

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the Non-Medical Necessity Coverage and Payment Rules section for other coverage criteria and payment information.

Coding Information

For Busulfan:

183.0 - 183.9

MALIGNANT NEOPLASM OF OVARY - MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE

200.00 - 200.88

RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 - 202.92

NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES

203.00 - 203.82

MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE

205.00 - 205.92

ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE

206.00 - 206.92

ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE

V10.43 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OVARY

V10.62 PERSONAL HISTORY OF MYELOID LEUKEMIA

V10.63 PERSONAL HISTORY OF MONOCYTIC LEUKEMIA

V10.71 PERSONAL HISTORY OF LYMPHOSARCOMA AND RETICULOSARCOMA

V10.79 PERSONAL HISTORY OF OTHER LYMPHATIC AND HEMATOPOIETIC NEOPLASMS

V42.81 BONE MARROW REPLACED BY TRANSPLANT For Capecitabine:

Coding Information

140.0 - 141.9

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

143.0 - 149.9

MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

150.0 - 150.9

MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE

151.0 - 151.9

MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

153.0 - 154.8

MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

156.0 - 156.9

MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 - 157.9

MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM

174.0 - 175.9

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

183.0 - 183.9


197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG

197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM

197.7 MALIGNANT NEOPLASM OF LIVER SECONDARY

Coding Information

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

235.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM

235.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS

V10.00 - V10.09

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT

V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST


V10.88 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES

For Cyclophosphamide:

140.0 - 149.9

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

151.0 - 151.9



160.0 - 161.9

MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED

162.0 - 162.9

MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

164.0 MALIGNANT NEOPLASM OF THYMUS

164.8 MALIGNANT NEOPLASM OF OTHER PARTS OF

Coding Information

MEDIASTINUM

170.0 - 170.9

MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

171.0 - 171.9

MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

173.1 - 173.9

OTHER MALIGNANT NEOPLASM OF SKIN OF EYELID INCLUDING CANTHUS - OTHER MALIGNANT NEOPLASM OF SKIN SITE UNSPECIFIED

174.0 - 175.9


180.0 - 180.9

MALIGNANT NEOPLASM OF ENDOCERVIX - MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE

181 MALIGNANT NEOPLASM OF PLACENTA

182.0 - 182.8

MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS

183.0 - 183.9


185 MALIGNANT NEOPLASM OF PROSTATE

186.0 - 186.9

MALIGNANT NEOPLASM OF UNDESCENDED TESTIS - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS

188.0 - 188.9

MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED

189.0 - 189.1

MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF RENAL PELVIS

190.5 MALIGNANT NEOPLASM OF RETINA

191.0 - MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES

Coding Information

191.9 AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM

194.0 MALIGNANT NEOPLASM OF ADRENAL GLAND

195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK





198.7 SECONDARY MALIGNANT NEOPLASM OF ADRENAL GLAND

200.00 - 200.88


201.00 - 201.98

HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 - 202.98

NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

203.00 - 203.82


204.00 - 204.92

ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE

205.00 - 205.92


Coding Information

206.00 - 206.92


209.30 - 209.36

MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE - MERKEL CELL CARCINOMA OF OTHER SITES

209.75 SECONDARY MERKEL CELL CARCINOMA

211.1 BENIGN NEOPLASM OF STOMACH

212.6 BENIGN NEOPLASM OF THYMUS

219.0 BENIGN NEOPLASM OF CERVIX UTERI

236.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLACENTA

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS

239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN

273.2 OTHER PARAPROTEINEMIAS

273.3 MACROGLOBULINEMIA

277.30 AMYLOIDOSIS, UNSPECIFIED

998.9 UNSPECIFIED COMPLICATION OF PROCEDURE NOT ELSEWHERE CLASSIFIED

V10.01 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TONGUE

V10.02 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF ORAL CAVITY AND PHARYNX

V10.04 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH

V10.11 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRONCHUS AND LUNG


V10.40 - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF

Coding Information

V10.48 UNSPECIFIED FEMALE GENITAL ORGAN - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF EPIDIDYMIS

V10.51 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BLADDER

V10.53 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RENAL PELVIS

V10.61 PERSONAL HISTORY OF LYMPHOID LEUKEMIA




V10.72 PERSONAL HISTORY OF HODGKIN'S DISEASE


V10.81 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BONE

V10.83 PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF SKIN

V10.84 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF EYE

V10.85 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRAIN


V10.89 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES

V10.91 PERSONAL HISTORY OF MALIGNANT NEUROENDOCRINE TUMOR

V42.81 BONE MARROW REPLACED BY TRANSPLANT For Etoposide:

150.0 - MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS -

Coding Information

150.9 MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE

151.0 - 151.9


155.0 - 155.2

MALIGNANT NEOPLASM OF LIVER PRIMARY - MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

158.8 - 158.9

MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM - MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

160.0 - 160.9

MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

162.0 - 162.9


163.0 - 163.9

MALIGNANT NEOPLASM OF PARIETAL PLEURA - MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED

164.0 MALIGNANT NEOPLASM OF THYMUS

164.1 - 164.9

MALIGNANT NEOPLASM OF HEART - MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED

165.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS

170.0 - 170.9


171.0 - 171.9


174.0 - 175.9


176.0 - KAPOSI'S SARCOMA SKIN - KAPOSI'S SARCOMA

Coding Information

176.9 UNSPECIFIED SITE

180.0 - 180.9



182.0 - 182.8


183.0 - 183.9


184.4 MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE


186.0 - 186.9


188.0 - 188.9


189.0 - 189.1

MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF RENAL PELVIS


191.0 - 191.9

MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE


193 MALIGNANT NEOPLASM OF THYROID GLAND

194.0 MALIGNANT NEOPLASM OF ADRENAL GLAND




Coding Information



199.0 - 199.2

DISSEMINATED MALIGNANT NEOPLASM - MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN

200.00 - 200.88


201.00 - 201.98


202.00 - 202.98

NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

203.00 - 203.82


204.00 - 204.92


205.00 - 205.02

ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE

205.20 - 205.22

SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MYELOID LEUKEMIA, IN RELAPSE

206.00 - 206.02

ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE

206.20 - 206.22

SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE

Coding Information

209.21 MALIGNANT CARCINOID TUMOR OF THE BRONCHUS AND LUNG

209.30 MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE

209.31 - 209.36

MERKEL CELL CARCINOMA OF THE FACE - MERKEL CELL CARCINOMA OF OTHER SITES


212.6 BENIGN NEOPLASM OF THYMUS


237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS

V10.03 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS

V10.04 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH

V10.07 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER



V10.40 - V10.44

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED FEMALE GENITAL ORGAN - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER FEMALE GENITAL ORGANS

V10.46 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE

V10.47 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TESTIS

V10.51 - V10.53

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BLADDER - PERSONAL HISTORY OF MALIGNANT

Coding Information

NEOPLASM OF RENAL PELVIS






V10.84 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF EYE


V10.87 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF THYROID




V42.81 BONE MARROW REPLACED BY TRANSPLANT For Fludarabine Phosphate:

200.00 - 200.88


201.00 - 201.98


202.00 - 202.98

NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING

Coding Information

LYMPH NODES OF MULTIPLE SITES

204.10 - 204.12

CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE

204.90 - 204.92

UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE

205.00 - 205.02


205.20 - 205.22


206.00 - 206.02


206.20 - 206.22



V10.61 - V10.63

PERSONAL HISTORY OF LYMPHOID LEUKEMIA - PERSONAL HISTORY OF MONOCYTIC LEUKEMIA




V42.81 BONE MARROW REPLACED BY TRANSPLANT For Mellphalan:

150.0 - 159.9

MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM

170.0 - MALIGNANT NEOPLASM OF BONES OF SKULL AND

Coding Information

170.9 FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

171.0 - 171.9


172.0 - 172.9

MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED

174.0 - 175.9


182.0 - 182.8


183.0 - 183.9



186.0 - 186.9



201.00 - 201.98


203.00 - 203.82


205.10 - 205.12

CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MYELOID LEUKEMIA, IN RELAPSE

206.10 - 206.12

CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA

Coding Information

CELLS


277.30 AMYLOIDOSIS, UNSPECIFIED

V10.03 - V10.09

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT


V10.42 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER PARTS OF UTERUS


V10.46 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE






V10.82 PERSONAL HISTORY OF MALIGNANT MELANOMA OF SKIN

V42.81 BONE MARROW REPLACED BY TRANSPLANT For Methotrexate:

140.0 - 149.9

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

150.0 - 150.9

MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE

Coding Information

151.0 - 151.9


153.0 - 154.8


155.0 - 155.2

MALIGNANT NEOPLASM OF LIVER PRIMARY - MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

157.0 - 157.9

MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.8 - 158.9

MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM - MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

160.0 - 161.9

MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED

162.0 - 162.9


163.0 - 163.9

MALIGNANT NEOPLASM OF PARIETAL PLEURA - MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED

164.1 - 164.9

MALIGNANT NEOPLASM OF HEART - MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED

165.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS

170.0 - 170.9


171.0 - 171.9


173.0 OTHER MALIGNANT NEOPLASM OF SKIN OF LIP

174.0 - 175.9


Coding Information

180.0 - 180.9



183.0 - 183.9



186.0 - 186.9


187.1 - 187.4

MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED

187.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS

188.0 - 188.9


189.1 - 189.8

MALIGNANT NEOPLASM OF RENAL PELVIS - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID


190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE

191.0 - 191.9


195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK


198.4 - 198.5

SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM - SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

Coding Information

200.00 - 202.98

RETICULOSARCOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

204.00 - 204.92


205.00 - 205.92


206.00 - 206.92


233.7 CARCINOMA IN SITU OF BLADDER

235.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF LIP ORAL CAVITY AND PHARYNX

235.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF LARYNX


238.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE

V10.00 - V10.09

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT


V10.21 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX

V10.22 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF NASAL CAVITIES MIDDLE EAR AND ACCESSORY SINUSES


V10.41 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF

Coding Information

CERVIX UTERI



V10.49 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER MALE GENITAL ORGANS

V10.50 - V10.59

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED URINARY ORGAN - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER URINARY ORGANS

V10.61 - V10.63

PERSONAL HISTORY OF LYMPHOID LEUKEMIA - PERSONAL HISTORY OF MONOCYTIC LEUKEMIA








For Temozolomide:

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

158.0 - 158.9

MALIGNANT NEOPLASM OF RETROPERITONEUM - MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

162.0 - MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT

Coding Information

162.9 NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

170.0 - 170.9


171.0 - 171.9


172.0 - 172.9

MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED

191.0 - 191.9



192.9 MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED





199.0 DISSEMINATED MALIGNANT NEOPLASM

199.1 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE

200.50 - 200.51

PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

204.00 - 204.02

ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

204.20 - SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION

Coding Information

204.22 OF HAVING ACHIEVED REMISSION - SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE

205.00 - 205.02


205.20 - 205.22


206.00 - 206.02


206.20 - 206.22


237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN

V10.09 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT






V10.82 PERSONAL HISTORY OF MALIGNANT MELANOMA OF SKIN



Coding Information


For Topotecan:

153.0 - 154.8



162.0 - 162.9


170.0 - 171.9

MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

174.0 - 175.9


180.0 - 180.9


182.0 - 182.8


183.0 - 183.9



188.0 - 188.9


189.0 - 189.2

MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF URETER

191.0 - 191.9



Coding Information





200.50 - 200.51

PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

203.00 - 203.82


204.00 - 205.92

ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE

206.00 - 206.02


206.20 - 206.22


209.30 MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE

209.31 - 209.36

MERKEL CELL CARCINOMA OF THE FACE - MERKEL CELL CARCINOMA OF OTHER SITES


238.71 - 238.76

ESSENTIAL THROMBOCYTHEMIA - MYELOFIBROSIS WITH MYELOID METAPLASIA

238.9 NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED

V10.05 -

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE - PERSONAL HISTORY OF

Coding Information

V10.06 MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID JUNCTION AND ANUS



V10.41 - V10.43

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF CERVIX UTERI - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OVARY

V10.51 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BLADDER








V16.49 FAMILY HISTORY OF MALIGNANT NEOPLASM OF OTHER

ICD-9 Codes that are Not Covered back to top

All codes not listed in the previous section.

No Coding Information has been entered in this section of the article.

Other Information

Other Information

Revision History Explanation back to top

Revision Effective Date: 06/01/2010 (August Publication) ICD-9 CODES THAT ARE COVERED: Added: Multiple diagnoses for all the drugs Revision Effective Date: 06/01/2010 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Clarified: Criterion 3 to indicate coverage for those ICD-9 diagnoses specifically indicated under IOM 100-02, Section 50 – Drugs and Biologicals and under the Social Security Act, Sec.1861(s)(Q). Added: Coverage possible at appeal for claims not listed in the section “ICD-9 Codes that are Covered ” which can be shown consistent with IOM 100-02, Section 50 – Drugs and Biologicals and with the Social Security Act, Sec.1861(s)(Q). ICD-9 CODES THAT ARE COVERED: Changed: All ICD-9 diagnoses to those specifically indicated under IOM 100-02, Section 50 – Drugs and Biologicals and under the Social Security Act, Sec.1861(s)(Q). Added: Diagnoses for fludarabine phosphate (effective 1/01/2010). Revision Effective Date: 10/01/2009 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Added: 208.92-209.36, 209.70-209.79 to accepted diagnoses for busulfan, capecitabine, cyclophosphamide, etoposide, melphalan, methotrexate, or temozolomide CODING GUIDELINES: Changed: SADMERC to PDAC ICD-9 CODES THAT ARE COVERED: Added: 208.92-209.36, 209.70-209.79 to accepted diagnoses for busulfan, capecitabine, cyclophosphamide, etoposide, melphalan, methotrexate, or temozolomide 08/08/2009 - This article was updated by the ICD-9 2009-2010 Annual Update. 08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update. Revision Effective Date: 04/01/2008 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Other Information

Expanded: Range of payable codes. Added: V58.11 ICD-9 CODES THAT ARE COVERED: Removed: V58.0-V58.10, V58.12. Added: Topotecan. Added: ICD-9 codes 162.2-162.9 for Topotecan 03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) Article A25619 from DME PSC TrustSolutions (77012) Article A25619. 09/03/2007 - This article was updated by the ICD-9 2007-2008 Annual Update. Revision Effective Date: 07/01/2007 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Removed: DMERC references CODING GUIDELINES: Removed: DMERC references 06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012). Revision Effective Date: 01/01/2007 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Specified that the quantity of drugs dispensed should be limited to a one month supply. Removed: DMERC references CODING GUIDELINES: Removed: DMERC references ICD-9 CODES THAT ARE COVERED: Expanded range of payable codes. Added: V58.0 – V58.12. 03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885). Revision Effective Date: 01/01/2006

Other Information

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Edited for Code changes Revised instructions for Supply Fee CODING GUIDELINES: Added: J8498 and J8597 Deleted: K0415 and K0416 Revision Effective Date: 10/01/2005 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Revised supply fee coverage for multiple dosage forms of the same drug. Effective Date: 04/01/2005 LMRP converted to LCD and Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Added: G0370 and instructions CODING GUIDELINES: Added: Instructions about the use of NDC numbers. ICD-9 CODES THAT ARE COVERED: Expanded range of payable codes

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