Bisphosphonate Drug Therapy (L30139)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation		 Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402		 Contractor Type
Carrier - FI- MAC

LCD Information

Document Information
LCD ID Number
L30139

LCD Title
Bisphosphonate Drug Therapy

Contractor's Determination Number
INJ-025

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 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.

Primary Geographic Jurisdiction
 
Oversight Region
 

Original Determination Effective Date
For services performed on or after 10/16/2009

Original Determination Ending Date


Revision Effective Date
For services performed on or after 02/21/2011

Revision Ending Date


CMS National Coverage Policy
Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act section 1862 (a)(1)(B). in the case of items and services described in section 1861(s)(10), which are not reasonable and necessary for the prevention of illness.

Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services

Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Medicare Benefit Policy Manual - Chapter 15 €“ Covered Medical and Other Health Services
54.1 - Approved Use of Drug - (Rev. 1, 10-01-03) (formerly B3-2049.4)

OTN Pub. 100-04; Change Request: 5645; SUBJECT: July, 2007 Quarterly Update to the HCPCS Codes for Albuterol, Levalbuterol, and Reclast®; Effective Date: July 1, 2007; Implementation Date: July 2, 2007
Indications and Limitations of Coverage and/or Medical Necessity
Bisphosphonate drugs act to inhibit normal and abnormal bone reabsorption. This action is helpful in reducing pain, reversing hypercalcemia, preventing and reducing fractures in a range of diseases that directly or indirectly impact bone modeling and remodeling.

These drugs are available in both oral and parenteral forms. Coverage by Medicare is limited to those drugs administered parenterally (IV). The names of these drugs and their route of administration are as follows:

Alendronate sodium (Fosamax) oral
Tiludronate sodium (Skelid) oral
Risedronate sodium (Actonel) oral
Etidronate disodium (Didronel) oral and IV (J1436)
Pamidronate disodium (Aredia) IV (J2430)
Zoledronic acid [Zoledronate], ((Zometa) IV (J3487)
Zoledronic acid, (Reclast) IV J3488
Ibandronate (Boniva) oral and IV (J1740)

Intravenous administration of bisphosphonate drug therapy is covered for FDA approved indications and for off-label indications when peer reviewed literature is available that supports additional coverage.

A. Etidronate disodium (Didronel) IV (J1436), Pamidronate disodium (Aredia) IV (J2430) and Zolendronic acid (Zoledronate) (Zometa) IV (J3487), are covered for the following indications:

1. Hypercalcemia associated with malignancy (275.42).
Osteoclastic hyperactivity resulting in excessive bone resorption is the underlying complication with metastatic bone disease and hypercalcemia associated with malignancy. Most cases of hypercalcemia, associated with malignancy, occurs in patients who have breast cancer, squamous-cell tumors of the lung or head and neck, renal-cell carcinoma, and certain hematologic malignancies (multiple myeloma and some types of lymphomas). Bisphosphonates, in conjunction with hydration, are indicated for moderate or severe hypercalcemia associated with malignancy with or without bone metastases.

2. Cancer treatment induced bone loss (733.09)

All oncology therapies that induce hypogonadism cause osteoporosis in a large percentage of patients unless hormone replacement is carried out immediately. Hypogonadism may occur in hormone-dependent tumors such as breast and prostate cancer; or it can be a consequence of cancer therapy in non hormone-dependant malignancies such as Hodgkin's and non-Hodgkin's lymphoma.

Cancer Treatment-Induced Bone Loss (CTIBL) in Breast and Prostate Cancer
Breast Cancer

Cytotoxic chemotherapy: There are 2 mechanisms of cytotoxic chemotherapy inducing bone loss. First, there is a direct negative effect of the cytotoxic therapy on bone cells, predominantly osteoblasts and, second, many women who are premenopausal have cytotoxic therapy effects on ovarian function, which results in gonadal loss. In addition, in premenopausal women, surgery (oophorectomy) or radiation therapy to the ovary results in bone loss. Hormone therapy, tamoxifen in premenopausal women, and the aromatase inhibitors result in bone loss, as well as gonadotropin-releasing hormone (GnRH) antagonists/agonists, which shut off ovarian function. All of these result in estrogen depletion.

Prostate Cancer

In prostate cancer, cytotoxic therapy again has a negative effect not only on testicular function but also on bone. Surgical therapy, hormone therapy, including antiandrogens and GnRH agonists/antagonists, results in androgen depletion. The final common pathway, estrogen and androgen depletion, results in a decrease in bone mineral density.

3. Bone metastases (198.5) secondary to solid tumors, breast cancer, prostate cancer

4. Multiple Myeloma (203.00, 203.01, 203.02)

5. Osteolytic lesions due to metastases (198.5)

6. Paget's Disease of bone (osteitis deformans) (731.0)
Intravenous bisphosphonates are indicated for moderate to severe Paget's disease of bone.

7. Prophylaxis and treatment of heterotopic ossification associated with spinal cord injury, traumatic brain injury, hip replacement, and burns. (728.10-728.12, 958.6)
- Etidronate disodium for this indication is usually given orally. It is indicated parenterally when the patient has failed a trial of the oral drug or has insurmountable issues related to absorption, compliance or dosing posture.

B. In addition to the above, Pamidronate Sodium (J2430) is covered for:

1. Osteogenesis Imperfecta (756.51)

2. Fibrous dysplasia of bone (756.54) (McCune-Albright syndrome) (756.59)

C. Ibandronate [Boniva] (effective with FDA approval 01/06/2006); Pamidronate: or Zolendronic acid (05/01/2006, off-label) Reclast® (August 17, 2007 FDA approval) are covered for:
1. Treatment of osteoporosis (733.00 -733.09) when;
Bisphosphonates remain the most appropriate anti-osteoporosis intervention, and there is no class contraindication or hypersensitivity to bisphosphonates, and there exists either:
- Demonstrated intolerance or contraindication for FDA approved oral bisphosphonates and oral dosing regimens, or insurmountable issues related to absorption, compliance or dosing posture, or
- When adequate trials of FDA-approved oral bisphosphonates result in fallen BMD and/or failure to suppress bone turnover (e.g. persisting high bone -turnover marker measurements.)

The World Health Organization (WHO) defines osteoporosis as spine, hip, or wrist bone mineral density (BMD) T-score <-2.5 or prevalent fragility fracture; and severe osteoporosis as T-score <-2.5 and prevalent fragility fracture

Evidence in the medical record should clearly support the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis.

The recommended dose of Boniva Injection for the treatment of postmenopausal osteoporosis is 3 mg every 3 months.

The recommended dose of Reclast® for treatment of postmenopausal osteoporosis is a single 5 mg infusion once a year given intravenously over no less than 15 minutes. (5 mg in a 100 mL ready to infuse solution)

D. Ibandronate [Boniva] Effective 10/16/2009
1. Hypercalcemia associated with malignancy (275.42).
2. Bone metastases (198.5) secondary to solid tumors, breast cancer, prostate cancer

E. Zoledronic acid, Reclast® - Injection is indicated for the treatment of:
1. Paget's disease of bone in men and women effective with FDA approval April 16, 2007.
Treatment is indicated in patients with Paget's disease of bone with elevations in serum alkaline phosphatase of two times or higher than the upper limit of the age-specific normal reference range, or those who are symptomatic, or those at risk for complications from their disease, to induce remission (normalization of serum alkaline phosphatase).

A single dose of Reclast® (zoledronic acid) Injection should not exceed 5 mg and the duration of infusion should be no less than 15 minutes.

WPS Medicare will cover Reclast at most once per year because after a single treatment with Reclast in Paget's disease an extended remission period is observed. Re-treatment with Reclast may be considered, after one year in patients who have relapsed, based on increases in serum alkaline phosphatase, or in those patients who failed to achieve normalization of their serum alkaline phosphatase, or in those patients with symptoms, as dictated by medical practice.

2. Osteoporosis Foundation Recommendations:
A hip or vertebral (clinical or morphometric) fracture,
Other prior fractures and low bone mass (T-score between -1.0 and -2.5 at the femoral neck, total hip or spine),
T-score < -2.5 at femoral neck, total hip or spine after appropriate evaluation to exclude secondary causes,
Low bone mass (T-score -1.0 to -2.5 at femoral neck, total hip or spine) and secondary causes associated with high risk of fracture (such as glucocorticoid use or total immobilization),
Low bone mass (T-score between -1.0 to -2.5 at femoral neck, hip or spine) with a 10-year probability of hip fracture greater than or equal to 3% or 10-year probability of any major osteoporosis-related fracture of greater than or equal to 20% based on the US-adapted WHO algorithm (FRAX).

AND one of the following criteria:

1. Documented allergy to shellfish and/or salmon derivatives.
2. Documented intolerance of oral bisphosphonate therapy due to medical or surgical conditions including but not limited to:
severe esophageal disease (e.g. ulcerations, strictures);
esophageal symptoms or dysphagia severe enough to cause patient non-compliance with oral bisphosphonates;
inability to take anything by mouth;
inability to sit or stand for at least 30 minutes; or
intestinal malabsorption.

3. Documented non-compliance with oral bisphosphonate treatment regimen of at least 3 months


Precautions
Hypocalcemia may occur with Reclast therapy. To reduce the risk of hypocalcemia, all patients should receive 1500 mg elemental calcium daily in divided doses (750 mg two times a day, or 500 mg three times a day) and 800 IU vitamin D daily, particularly in the 2 weeks following Reclast administration.
Reclast may cause fetal harm when administered to a pregnant woman. Reclast should not be used during pregnancy.
Reclast is not recommended for use in patients with severe renal impairment (creatinine clearance <35mL/min) due to lack of adequate clinical experience in this population. Reclast has been associated with heart arrhythmia problems in the form of atrial fibrillation.

E. Bisphosphonates can impact renal function. Monitoring of renal function before during and post treatment according to labeled recommendations would be expected.

F. Monitoring with appropriate laboratory tests such as calcium, magnesium, and phosphate may be recommended.

G. The Food and Drug Administration has notified the public to the problem of osteonecrosis (also described as avascular or aseptic necrosis) of the mandible and/or maxilla, occurring in association with intravenously administered bisphosphonates.

H. A Severe anterior uveitis has been reported with use of bisphosphonate therapy.

I. The U.S. Food and Drug Administration (FDA) is updating the public regarding information previously communicated describing the risk of atypical fractures of the thigh, known as subtrochanteric and diaphyseal femur fractures, in patients who take bisphosphonates for osteoporosis
Atypical subtrochanteric femur fractures are fractures in the bone just below the hip joint. Diaphyseal femur fractures occur in the long part of the thigh bone. These fractures are very uncommon and appear to account for less than 1% of all hip and femur fractures overall. Although it is not clear if bisphosphonates are the cause, these unusual femur fractures have been predominantly reported in patients taking bisphosphonates.
The bisphosphonates affected by this notice are only those approved to treat osteoporosis, including Fosamax, Fosamax Plus D, Actonel, Actonel with Calcium, Boniva, Atelvia, and Reclast (and their generic products).
This notice does not affect bisphosphonate drugs that only are used to treat Paget's disease or high blood calcium levels due to cancer (i.e., Didronel, Zometa, Skelid, and their generic products

Although the optimal duration of bisphosphonate use for osteoporosis is unknown, these atypical fractures may be related to long-term term bisphosphonate use.
Bisphosphonate medications approved for the prevention and/or treatment of osteoporosis have clinical trial data supporting fracture reduction efficacy through at least 3 years of treatment and, in some cases, through 5 years. The FDA is continuing its evaluation of data supporting the safety and effectiveness of long term use (greater than 3 to 5 years) of bisphosphonates for the treatment and prevention of osteoporosis and will provide additional guidance at the completion of our review.


Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.
0636 Pharmacy - Drugs Requiring Detailed Coding

CPT/HCPCS Codes
CPT/HCPCS Codes
J1436 INJECTION, ETIDRONATE DISODIUM, PER 300 MG
J1740 INJECTION, IBANDRONATE SODIUM, 1 MG
J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG
J3487 INJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MG
J3488 INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG

ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity

To report Low bone mass (T-score -1.0 to -2.5 at femoral neck, total hip or spine) for code J3488 use ICD-9 code 733.00

J1436 Etidronate
198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01 MULTIPLE MYELOMA IN REMISSION
203.02 MULTIPLE MYELOMA, IN RELAPSE
275.42 HYPERCALCEMIA
728.10 - 728.12 CALCIFICATION AND OSSIFICATION UNSPECIFIED - TRAUMATIC MYOSITIS OSSIFICANS
731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR
958.6 VOLKMANN'S ISCHEMIC CONTRACTURE

J3487 Zolendronic acid (Zoledronate) (Zometa)


198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01 MULTIPLE MYELOMA IN REMISSION
203.02 MULTIPLE MYELOMA, IN RELAPSE
275.42 HYPERCALCEMIA
728.10 - 728.12 CALCIFICATION AND OSSIFICATION UNSPECIFIED - TRAUMATIC MYOSITIS OSSIFICANS
731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR
733.00 - 733.09 OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS
958.6 VOLKMANN'S ISCHEMIC CONTRACTURE

J3488 Zolendronic acid (Reclast)
731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR
733.00 - 733.09 OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS

J2430 Pamidronate only


198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01 MULTIPLE MYELOMA IN REMISSION
203.02 MULTIPLE MYELOMA, IN RELAPSE
275.42 HYPERCALCEMIA
728.10 - 728.12 CALCIFICATION AND OSSIFICATION UNSPECIFIED - TRAUMATIC MYOSITIS OSSIFICANS
731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR
733.00 - 733.09 OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS
756.51 OSTEOGENESIS IMPERFECTA
756.54 POLYOSTOTIC FIBROUS DYSPLASIA OF BONE
756.59 OTHER CONGENITAL OSTEODYSTROPHIES
958.6 VOLKMANN'S ISCHEMIC CONTRACTURE

J1740 Ibandronate (Boniva)

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
275.42 HYPERCALCEMIA
733.00 - 733.09 OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS


Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity
733.90 Disorder of bone and cartilage unspecified is listed as a code to use for osteopenia. The policy does not support the use of this code as well as any codes not listed above.
733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements
1. If bone metastases is the condition being treated, the claim must be submitted with the ICD-9 code that reflects the reason for the service (198.5). The diagnosis of a primary malignant neoplasm must be present in the patient's progress notes, and available if requested.

2. Intravenous administration by infusion should be billed with codes 96365 for first hour and code 96366 for each additional hour. If the administration is by IV push use code 96374.

Information in the medical record should support the medical necessity of this service based on the indications listed and be available on request. ICD-9 codes supporting medical necessity should be submitted on the claim.
Appendices
Utilization Guidelines
Utilization Guidelines
See Indications and Limitations


This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Sources of Information and Basis for Decision
Sources of Information and Basis for Decision
Drug Facts and Comparisons, 2001 Edition
Liens, Daniel et. al.; Long-term Effects of Intravenous Pamidronate in Fibrous Dysplasia of Bone; Lancet; Vol. 343, 04/16/94
Rosen, Les S., et al.; Zoledronic Acid Versus Pamidronate in the Treatment of Skeletal Metastases in Patients With Breast Cancer or Osteolytic Lesions of Multiple Myeloma: A Phase III, Double Blind Comparative Trial; The Cancer Journal: Vol. 7, NO. 5, Sept/Oct/2001.
Berenson, James R. et. al.; Zoledronic Acid Reduces Skeletal-Related Events in Patients with Osteolytic Metastases; CANCER: Vol. 17, NO 1; 03/2000.
Osteoporosis Prevention Diagnosis and Therapy; NIH Consensus Statement Vol. 17, NO 1, 03/2000
Glorieux, F.H., et al. Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. New England Journal of Medicine 1998 Oct. 1; 339(14): 947-952.
Recommendations for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis; Arthritis and Rheumatism, Vol. 44, NO 7, 07/2001, pg. 1496-1503
AACE 2001 Medical Guidelines For Clinical Practice For the Prevention and Management of Postmenopausal Osteoporosis; Endocrine Practice, Vol. 7, NO. 4 July/August 2001
Banovac, K., The effect of etidronate on the late development of heterotopic ossification after spinal cord injury, J. Spinal Cord Med., 200 Spring; 23(1): 40-4.
Campagnolo, Denise I.,et.al.; Heterotopic Ossification in Spinal Cord Injury; eMedicine Journal, June 22,2001, Volume 2, No. 6.
Russell, R. G.G., and Rogers, M.J.; Bisphosphonates: from the laboratory to the clinic and back again; Bone; Vol.25, Issue 1, 07/1999
Smith, Matthew R., et. al.; Randomized Controlled Trial of Zolendronic Acid to Prevent Bone Loss in Men Receiving Androgen Deprivation Therapy for Nonmetastatic Prostate Cancer; Journal of Urology, Vol. 169, No 6, June, 2003
Hilner, Bruce E., et. al.; American Society of Clinical Oncology 2003 Update On The Role of Bisphosphonates and Bone Health Issues in Women with Breast Cancer; Journal of Clinical Oncology, Vol. 21, Nov., 2003
Pfeilschifter, Johannes and Deil, Ingo J.; Osteoporosis Due to Cancer Treatment: Pathogenesis and Management; Journal of Clinical Oncology, Vol. 18, No 7, April, 2000
Reid Ian R., M.D; et.al,; Intravenous Zoledronic Acid in Postmenopausal Women with Low Bone Mineral Density; Volume 346:653-661; February 28, 2002; Number 9
Black, Dennis M., Delmas Pierre D., et al; Once-Yearly Zoledronic Acid for Treatment of postmenopausal Osteoporosis; NEJM, 05/03/07; Vol. 356 No. 18
FDA approval Letter dated 04/16/2007 for coverage of Reclast® (zoledronic acid) for Pagets disease of the bone.
FDA approval Letter dated 08/17/2007 for coverage of Reclast® (zoledronic acid) for post-menopausal osteoporosis.
Pecherstorfer M, Herrmann Z, Body JJ, et al. Randomized phase II trial comparing different doses of the bisphosphonate ibandronate in the treatment of hypercalcemia of malignancy. J Clin Oncol. 1996;14(1):268-276.
Pecherstorfer, M, Rivkin S, Body JJ, et al. Long-term safety of intravenous ibandronic acid for up to 4 years in metastatic breast cancer: An open-label trial. Clin Drug Investig. 2006;26(6):315-322.
Guay DR. Ibandronate, an experimental intravenous bisphosphonate for osteoporosis, bone metastases, and hypercalcemia of malignancy. Pharmacotherapy. 2006;26(5):655-673.
Diel IJ, Body JJ, Lichinitser, MR, et al.; MF 4265 Study Group. Improved quality of life after long-term treatment with the bisphosphonate ibandronate in patients with metastatic bone disease due to breast cancer. Eur J Cancer. 2004;40(11):1704-1712.
Body JJ, Diel IJ, Lichinitser, MR, et al.; MF 4265 Study Group. Intravenous ibandronate reduces the incidence of skeletal complications in patients with breast cancer and bone metastases. Ann Oncol. 2003;14(9):1399-1405.
Pecherstorfer, M, Steinhauer EU, Rizzoli R, et al. Efficacy and safety of ibandronate in the treatment of hypercalcemia of malignancy: A randomized multicentric comparison to pamidronate. Support Care Cancer. 2003;11(8):539-547.
*The Clinician's Guide to Prevention and Treatment of Osteoporosis 2010 http://www.nof.org/professionals/clinical-guidelines
*FDA Drug Safety Communication: Safety update for osteoporosis drugs, bisphosphonates, and atypical fractures [10-13-2010]
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 05/15/2009
Illinois 05/13/2009
Michigan 05/06/2009
Minnesota 05/21/2009
J5 MAC 06/04/2009
Start Date of Comment Period
06/04/2009
End Date of Comment Period
07/20/2009
Start Date of Notice Period
11/01/2010
Revision History Number
5
Revision History Explanation
11/01/2010, Removed section on non-coverage of Reclast for prevention of osteoporosis and added the Osteoporosis Foundation Recommendations and added FDA warning about fractures

04/01/2010 added section on non-coverage of Reclast for prevention of osteoporosis

02/01/2010, ICD-9 codes 728.10-728.12 and 958.6 were added to the list of payable codes for J2430 and J3487. This is a correction of a typo.;

11/01/2009, Corrected ICD-9 coding 203.02. Added instructions for iv administration. Remove revenue codes 0634 and 0635.

09/08/2009 Updated intravenous admin text (first paragraph) under Indications and Limitations. Updated ICD-9 code under J1740.

08/14/2009 Revised draft and Released to final effective date will be 10/16/2009

06/29/2009 removed contractor number 05392 for EMO because it is joining with WMO to be under one contractor number effective 8/1/09

04/03/2009 Approved
04/02/2009 Added as new draft LCD AB

3/7/2010 - The description for Bill Type Code 73 was changed
3/7/2010 - The description for Bill Type Code 77 was changed

04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor  Palmetto.

8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 23 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 72 was changed
8/1/2010 - The description for Bill Type Code 73 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0636 was changed

10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).

02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
Reason for Change
Last Reviewed On Date
10/01/2010
Related Documents
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