Chemotherapy Drugs and their Adjuncts (L28576)

Contractor Information

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

LCD Information

Document Information
LCD ID Number
L28576

LCD Title
Chemotherapy Drugs and their Adjuncts

Contractor's Determination Number
HONC-010

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2011 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 05/16/2009

Original Determination Ending Date


Revision Effective Date
For services performed on or after 04/01/2012

Revision Ending Date


CMS National Coverage Policy
CMS Pub.100-2 Chapter 15; Section 50
CMS Pub 100-20 OTN-129, CR 3631
CMS Pub 100-04 Chapter 12; Section 30.5
CMS Pub 100-04 Chapter 14; Section 10
CMS Pub 100-04 Chapter 17; Section 90.2
Change Request 71111- October 2010 Integrated Outpatient Code Editor (I/OCE) Specifications Version 11.3
Change Request (CR) 7303 Quarterly HCPCS Drug/Biological Code Changes July 2011 Update
CR 7445- July 2011 Update of the Ambulatory Surgical Center (ASC) Payment System

Indications and Limitations of Coverage and/or Medical Necessity
A. Coverage for medication is based on the patient's condition, the appropriateness of the dose and route of administration, based on the clinical condition and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition. The drug must be used according to the indication and protocol listed in the accepted compendia ratings listed below.

National Comprehensive Cancer Network (NCCN) Drugs and Biologies Compendium
Thomson Micromedex DrugDex
American Hospital Formulary Service-Drug Information (AHFS-DI)
Clinical Pharmacology

The compendia employ various rating and recommendation systems that may not be readily cross-walked from compendium to compendium. In general, a use is identified by a compendium as medically accepted if the:
1. indication is a Category 1 or 2A in NCCN, or Class I, Class IIa or Class IIb in DrugDex; or
2. narrative text in AHFS-DI or Clinical Pharmacology is supportive.

B. The following well-established drugs will be allowed for cancer therapy and for other therapy as indicated. (ICD-9 codes 140.0-239.9)

1. Bleomycin sulfate, 15 units (Blenoxane) (J9040)
Verruca - 078.10 - 078.12, 078.19
2. Carboplatin 50 mg, (Paraplatin) (J9045)
3. Carmustine 100 mg, (BCNU, BiCNU) (J9050)
4. Cisplatin (Platinol) powder or solution, per 10 mg (J9060)
5. Cyclophosphamide (Cytoxan) 100 mg (J9070)
See section F for non-oncological uses.

6. Cytarabine 100 mg. (J9100)
7. Dacarbazine (DTIC) 100 mg (J9130)
8. Dactinomycin 0.5mg (actinomycin-D, Cosmegen) (J9120)
9. Doxorubicin Hydrochloride 10 mg (Adriamycin) (J9000) 273.3
10. Diethylstilbestrol Diphosphate, 250 mg (J9165)
11. Etoposide (VePesid) 10 mg (J9181) Etopside phosphate (Etopophos) 273.3
12. Floxuridine (FUDR) 500 mg (J9200)
13. Fluorouracil (5FU, Adrucil) 500 mg (J9190)
glaucoma (365.10-365.65, 365.70-365.73, 365.81-365.9) for patients at high risk for filtering surgery failure.
Verruca - 078.10 -078.12, 078.19
14. Ifosfamide 1 gram (J9208)
15. Leucovorin calcium, per 50 mg (J0640)
16. Levoleucovorin calcium, 0.5mg (J0641)
17. Mechlorethamine hydrochloride (Nitrogen Mustard), 10 mg (J9230)
18. Mesna 200 mg (Urothelial Protectant used in combination with cyclophosphamide or Ifosfamide) 595.9 (J9209)
19. Methotrexate Sodium ; (MTX, Folex) 5 mg (J9250), Methotrexate Sodium ; (MTX, Folex) 50 mg (J9260) See section F for non-oncological uses.
20. Plicamycin 2.5mg (Mithracin) (J9270)
21. Mitomycin (Mutomycin) 5 mg (J9280). (Mitomycin C used during eye surgery is considered a part of the procedure).
22. Thiotepa 15 mg (J9340)
23. Vinblastine sulfate (Velban) 1 mg (J9360)
24. Vincristine (Oncovin) 1 mg (J9370), (273.3-Waldenstrom's Macroglobulinemia, 283.0, 287.4 autoimmune hemolytic anemia or thrombocytopenia)

C. The following drugs are covered for the following indications:

1. Aldesleukin .per single use vial, (J9015) (Proleukin) (Interleukin-2)
Acute myelogenous Leukemia 205.00-205.02
Melanoma 172.0-172.9, 190.9 (effective 05/16/09)
Renal Cell 189.0, 189.1
Non-Hodgkin's lymphoma 200.00-200.88, 202.00-202.98

2. Alemtuzumab 10 mg (Campath) (J9010)
Chronic lymphocytic leukemia 204.10, 204.11, 204.12
Mycosis fungoides, Sezary's Disease 202.10-202.18, 202.20-202.28
T-Cell prolymphocytic leukemia 204.80, 204.82

3. Arsenic Trioxide (Trisenox) 1mg (J9017)
Acute Promyelocytic leukemia (APL) 205.00-205.02
Chronic Myeloid Leukemia 205.10, 205.11, 205.12
Multiple Myeloma 203.00-203.02
Myelodysplastic Syndromes 238.72-238.76

4. Asparaginase, (Elspar) 10,000 units (J9020)
Acute lymphocytic leukemia 204.00-204.02
Acute non-lymphocytic leukemia 205.00-205.02, 205.10-205.12, 205.20-205.22, 205.30-205.32, 205.80-205.82, 205.90-205.92, 206.00-206.02, 206.10-206.12, 206.20-206.22, 206.80-206.82, 206.90-206.92, 207.00-207.02, 207.10-207.12, 207.20-207.22, 207.80-207.82, 208.00-208.02,
Chronic lymphocytic leukemia 204.10, 204.12
Hodgkin's lymphoma 201.90-201.98
Soft tissue sarcoma, melanosarcoma 172.0-172.9
Non-Hodgkin's lymphoma 200.00-200.88, 202.00-202.98

5. Azacitidine (Vidazaâ„¢) (J9025), 1 mg
Myelodysplastic Syndrome 238.72-238.76
Acute myelogenous leukemia 205.00-205.02
Chronic Myeloid leukemia 205.10, 205.12

6. BCG (Intravesical), per installation (J9031)
Bladder 188.0-188.9, 233.7

7. Bendamustine hydrochloride (Treandaâ„¢), 1 mg J9033
Chronic lymphocytic leukemia (CLL) 204.10-204.11, 204.12.
Non-Hodgkin's Lymphoma (NHL) 200.00-200.88, 202.00-202.98
Waldenstrom's Macroglobulinemia 273.3
Multiple Myeloma 203.00-203.02

Bendamustine hydrochloride is covered for the treatment of patients with indolent B-cell non-Hodgkin's lymphoma (NHL) that has progressed during or within six months of treatment with rituximab or a rituximab-containing regimen.

8. Bevacizumab (Avastin â„¢)(J9035), 10 mg
Breast Cancer
Covered for the treatment of metastatic breast cancer, HER-2 negative disease, for first line therapy in combination with paclitaxel.
174.0-175.9
Colorectal Cancer 153.0-154.8
Non-Small cell lung cancer 162.2-162.9
Glioma 191.0-191.9
Ovarian Cancer 183.0-183.9
Renal Cell Cancer 189.0, 189.1
Malignant neoplasm of retroperitoneum and peritoneum 158.0, 158.8, 158.9
Soft Tissue Sarcomas 171.0-171.9


9. Bortezomib (Velcadeâ„¢) (J9041), 0.1mg
Anaplastic large cell lymphoma 200.60-200.68
Peripheral T-cell lymphoma 202.70-202.78
Other Lymphomas 202.80-202.88
Multiple Myeloma 203.00-203.02
Mantle cell lymphoma 200.40-200.48
Amyloidosis 277.30
Waldenstrom's Macroglobulinemia 273.3

Primary chemotherapy for progressive solitary plasmacytoma or smoldering myeloma (asymptomatic) that has progressed to active (symptomatic) myeloma (203.80 or 238.6) in:

-combination with dexamethasone with or without cyclophosphamide, doxorubicin, lenalidomide, or thalidomide for transplant candidates (all preferred regimens)

-combination with dexamethasone or in MPB (melphalan, prednisone, and bortezomib) regimen for nontransplant candidates (all preferred regimens)


10. Cabazitaxel (Jevtana®) (J9043) 1 mg, effective 07/17/10 FDA approval date
Microtubular inhibitor indicated in combination with prednisone for treatment of hormone refractory metastatic prostate cancer (185) previously treated with a docetaxel containing regimen.


11. Cetuximab (Erbituxâ„¢) (J9055) 10 mg
Colorectal Cancer 153.0-154.8
Head and Neck Cancer 140.0-149.9, 160.0-161.9, 195.0, 196.0
Non-Small cell lung cancer 162.2-162.9
Squamous Cell Skin Cancer of the head and neck 173.02, 173.12, 173.22, 173.32, 173.42
Squamous Cell Skin Cancer for Regional Recurrences or Distal Metastases 239.2 or V10.83.

Cetuximab is covered when:
Used in combination with irinotecan, is indicated for the treatment of metastatic colorectal carcinoma in patients who are refractory to irinotecan-based chemotherapy.
-Administered as a single agent for the treatment of patients with metastatic colorectal carcinoma in patients who are intolerant to irinotecan based chemotherapy.

The patient must not have K-RAS mutation when using this drug for the treatment of colorectal cancer.

-As a single agent or in combination with irinotecan after first progression except in patients receiving capecitabine or fluorouracil and leucovorin with bevacizumab.

Cetuximab is a recombinant, human/mouse (chimeric) monoclonal antibody. If the patient has disease progression on an Epidermal Growth Factor Receptor (EGRF) monoclonal antibody, it would not be appropriate to use this drug.

12. Cladribine Chlorodexyadenoside (2-CDA) (Leustatin) per 1 mg (J9065)
Hairy Cell Leukemia 202.40-202.48
Non-Hodgkin's Lymphoma 200.00-200.88; 202.00-202.98
Waldenstrom's Macroglobulinemia 273.3
Chronic Lymphocytic Leukemia 204.10, 204.11, 204.12
Cutaneous T-Cell Lymphomas 202.00-202.98

13. Cytarabine Liposome (Depocytâ„¢) 10 mg (J9098)
Intrathecal treatment of lymphomatous meningitis-Secondary malignant neoplasm of other parts of nervous system 198.4

14. Daunorubicin, 10 mg (J9150)
Acute Lymphocytic Leukemia 204.00, 204.01, 204.02
Acute Nonlymphocytic Leukemia 2205.00-205.02, 205.10-205.12, 205.20-205.22, 205.30-205.32, 205.80-205.82, 205.90-205.92, 206.00-206.02, 206.10-206.12, 206.20-206.22, 206.80-206.82, 206.90-206.92, 207.00-207.02, 207.10-207.12, 207.20-207.22, 207.80-207.82, 208.00-208.02,
Ewing's Sarcoma 170.0-170.9
Kaposi's Sarcoma 176.0-176.9
Neuroblastoma 160.0-160.9, 194.0-194.9
Non-Hodgkin's Lymphomas 200.00-200.88, 202.00-202.98
Wilms' Tumor 189.0

15. Daunorubicin citrate, liposomal formulation, (DaunoXome) 10 mg (J9151)
Kaposi's Sarcoma 176.0-176.9


16. Decitabine (Dacogen) (J0894)
Myelodysplastic Syndrome 238.72-238.76
Acute Myeloid Leukemia 205.00, 205.01, 205.02
Chronic Myelomonocytic leukemia 205.10, 205.12

17. Denileukin Diftitox (Ontak) 300 micrograms (J9160)
Cutaneous T-Cell Lymphomas 202.00-202.98

18. Docetaxel (Taxotere) 1mg (J9171)
Breast Cancer 174.0-175.9
Bladder 188.0-188.9, 233.7
Esophagus 150.0-150.9
Head and Neck 140.0-149.9, 160.0-161.9, 195.0
Lung Cancer 162.2-162.9
Ovarian Cancer 183.0-183.9
Peritoneal cancer 158.0-158.9
Prostate 185,
Soft Tissue Sarcomas 171.0-171.9
Stomach 151.0-151.9
Kidney, Renal pelvis, Ureter 189.0, 189.1, 189.2
Uterine/endometrial Cancer 182.0-182.8
Osteosarcoma 170.0-170.9

19. Doxorubicin Hydrochloride, all lipid formulations, 10 mg (Doxil) (J9001)
Breast Cancer 174.0-175.9
Refractory ovarian cancer 183.0-183.9
Kaposi's Sarcoma 176.0-176.9
Multiple Myeloma 203.00-203.02
Peritoneal cancer 158.0-158.9
Bladder 188.0-188.9, 233.7
Hodgkin disease-Second line treatment prior to autologous stem cell rescue in patients initially treated with chemotherapy alone or in combination with radiation therapy. 201.50-201.58, 201.60-201.68, 201.70-201.78, 201.90-201.98
Malignant neoplasm of connective and other soft tissue-trunk 171.0-171.9
Endometrial Cancer when used as:
A primary treatment as a single agent:
-with sequential radiation therapy (RT), surgery, and brachytherapy for extrauterine pelvic disease
-consider following palliative hysterectomy with bilateral salpingo-oophorectomy, RT, and hormonal therapy for extra-abdominal or liver disease.
For completely surgically staged patients as a single agent:
-with or without sequential tumor-directed RT for stage IIIA, IIIB, and IIIC disease
-with or without sequential RT for stage IV disease
182.0

20. Epirubicin Hydrochloride (Ellence) 2 mg (J9178)
Breast Cancer 174.0-175.9
Esophagus 150.0-150.9
Hodgkin's Lymphoma 201.00-201.98
Lung 162.2-162.9
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Ovary 183.0-183.9
Peritoneal cancer 158.0-158.9
Soft tissue sarcomas 171.0-171.9
Stomach 151.0-151.9

21. Eribulin mesylate (Halaven) (J9179), 0.1mg FDA Approved 11/15/2010
For the treatment of patients with metastatic breast cancer who have previously received at least two chemotherapeutic regimens for the treatment of metastatic disease. Prior therapy should have included anthracycline and a taxane in either the adjuvant or metastatic setting (174.0-174.9, 175.0-175.9).

22. Fludarabine Phosphate (Fludara) 50 mg (J9185)
Cutaneous T-Cell Lymphomas 202.00-202.98
Prolymphocytic Leukemia 204.90-204.92
Chronic Lymphocytic Leukemia 204.10, 204.11, 204.12
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Waldenstrom's Macroglobulinemia 273.3
Acute non-lymphocytic Leukemia 205.00-205.02, 205.10-205.12, 205.20-205.22, 205.30-205.32, 205.80-205.82, 205.90-205.92, 206.00-206.02, 206.10-206.12, 206.20-206.22, 206.80-206.82, 206.90-206.92, 207.00-207.02, 207.10-207.12, 207.20-207.22, 207.80-207.82, 208.00-208.02
Peripheral stem cell transplant V42.82

23. Fulvestrant (Faslodexâ„¢) 25mg (J9395)
Hormone receptor-positive metastatic breast cancer in postmenopausal women with disease progression following anti-estrogen therapy
Breast Cancer 174.0-175.9

24. Gemcitabine Hydrochloride (Gemzar) 200 mg (J9201)
Bladder 188.0-188.9, 233.7
Biliary tract 156.1, 156.2, 156.8, 156.9
Breast Cancer 174.0-175.9
Gallbladder, extrahepatic bile ducts 156.0-156.9
Head and Neck 140.0-149.9, 160.0-161.9, 195.0
Hodgkin's Lymphoma 201.00-201.98
Intrahepatic bile ducts 155.1
Mesothelioma 158.0-158.9, 163.0-163.9
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Non-Small cell lung cancer 162.2-162.9
Ovary 183.0-183.9
Peritoneal cancer 158.0-158.9
Pancreatic Cancer 157.0-157.9
Soft Tissue Sarcomas 171.0-171.9
Testes (germ cell) 186.0.0-186.9
Kidney, Ureter 189.0-189.2
Carcinoma of unknown primary Chemoradiation in combination with cisplatin or docetaxel in symptomatic patients with performance status 1-2 or asymptomatic patients with aggressive disease for localized disease with inguinal nodal involvement
199.0, 199.1
Osteosarcoma 170.0-170.9
Uterine -as a single agent or used in combination with docetaxel for unresectable disease limited to the uterus. May be considered following hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) for stage I-III disease 179, 180.0, 182.0-182.8

25. Gemtuzumab Ozogamicin (Mylotarg) 5mg (J9300)
(CD33 positive)
Acute Myeloid Leukemia 205.00, 205.01, 205.02

26. Idarubicin Hydrochloride 5 mg (Idamycin) (J9211)
Acute lymphocytic leukemia 204.00, 204.01, 204.02
Acute non-lymphocytic leukemia 205.00-205.02, 205.10-205.12, 205.20-205.22, 205.30-205.32, 205.80-205.82, 205.90-205.92, 206.00-206.02, 206.10-206.12, 206.20-206.22, 206.80-206.82, 206.90-206.92, 207.00-207.02, 207.10-207.12, 207.20-207.22, 207.80-207.82, 208.00-208.02
Myelodysplastic Syndrome 238.72-238.76

27. Interferon, alpha - 2A, recombinant 3 million units (Roferon A) (J9213)
Bladder 188.0-188.9, 233.7
Brain 191.0-191.9
Carcinoid Syndrome 259.2
Cervix 180.0-180.9
Chronic Non A/B hepatitis 070.44, 070.54
Chronic Myelocytic Leukemia 205.10-205.12
Colorectal 153.0-154.8
Cutaneous T-Cell Lymphoma 173.0-173.9, 202.00-202.98
Essential/Idiopathic Thrombocythemia 238.71
Hairy Cell Leukemia 202.40-202.48
Head and Neck 140.0-149.9, 160.0-161.9, 195.0
Kaposi's Sarcoma 176.0-176.9
Kidney 189.0, 189.1
Melanoma 172.0-172.9
Multiple Myeloma 203.00-203.01, 203.10
Non-Hodgkin's Lymphomas 200.00-200.88, 202.00-202.98
Osteosarcoma 170.0-170.9
Ovary 183.0-183.9
Peritoneal cancer 158.0-158.9
Pancreas 157.0-157.9
Skin 173.00-173.99

28. Interferon, alpha-2B, recombinant, 1 million units (Intron A) (J9214)
Bladder 188.0-188.9, 233.7
Carcinoid Syndrome 259.2
Cervix 180.0-180.9
Polycythemia Vera 238.4
Chronic Lymphocytic Leukemia 204.10, 204.11, 204.12
Chronic Myelocytic Leukemia 205.10-205.12
Colorectal 153.0-154.8
Cutaneous T-Cell Leukemia 173.0-173.9, 202.00-202.98
Essential /idiopathic Thrombocythemia 238.71
Hairy Cell Leukemia 202.40-202.48
Head and Neck 140.0-149.9, 160.0-161.9, 195.0
Kaposi's Sarcoma 176.0-176.9
Kidney 189.0, 189.1
Melanoma 172.0-172.9
Multiple Myeloma 203.00-203.02
Non-Hodgkin's Lymphomas 200.00-200.88, 202.00-202.98
Ovary 183.0-183.9
Peritoneal cancer 158.0-158.9
Pancreas 157.0-157.9
Skin 173.00-173.99

Other Indications:
Condylomata Acuminata 078.10 - 078.12, 078.19
Chronic Hepatitis Non A, Non B/C; 070.44, 070.54
Chronic Hepatitis B 070.32

29. Interferon, Alfa-N3 (Human Leukocyte Derived) 250,000 IU (Alferon N)(J9215)
Bladder 188.0-188.9, 233.7
Chronic Myelocytic Leukemia 205.10, 205.11, 205.12
Hairy Cell Leukemia 202.40-202.48
Kaposi's Sarcoma 176.0-176.9
Kidney 189.0, 189.1
Melanoma 172.0-172.9
Multiple Myeloma 203.00-203.02, 203.10, 203.12
Non-Hodgkin's Lymphomas 200.00-200.88, 202.00-202.98

Other Indications:
Condylomata Acuminata 078.10 - 078.12, 078.19

30. Ipilimumab (Yervoyâ„¢) 1mg, (J9228) effective 03/25/11 (FDA approval date)
For the treatment of unresectable or metastatic melanoma 172.0-172.9

31. Irinotecan (Camptosar) 20 mg (J9206)
Cervical Cancer 180.0-180.9
Colorectal Cancer 153.0-154.8
Esophageal Cancer 150.0-150.9
Gastric Cancer 151.0-151.9
Glioma 191.0-191.9
Lung Cancer 162.2-162.9
Ovarian 183.0-183.9
Pancreas 157.0-157.9
Ewings Sarcoma 170.0-170.9
Locally recurrent or metastatic breast cancer 174.0-175.9
Carcinoma of unknown primary 199.0, 199.1

32. Ixabepilone (Ixempraâ„¢), 1mg (J9207 )
Breast (174.0-175.9)

Ixabepilone is indicated in combination with capecitabine for the treatment of patients with metastatic or locally advanced breast cancer resistant to treatment with an anthracycline and a taxane, or whose cancer is taxane resistant and for whom further anthracycline therapy is contraindicated.

Anthracycline resistance is defined as progression while on therapy or within 6 months in the adjuvant setting or 3 months in the metastatic setting. Taxane resistance is defined as progression while on therapy or within 12 months in the adjuvant setting or 4 months in the metastatic setting.

Ixabepilone is indicated as monotherapy for the treatment of metastatic or locally advanced breast cancer in patients whose tumors are resistant or refractory to anthracyclines, taxanes, and capecitabine.

33. Melphalan Hydrochloride (Alkeran) (J9245) per 50 mg
Osteosarcoma 170.0-170.9
Soft Tissue Sarcomas 171.0-171.9
Melanoma 172.0-172.9
Breast 174.0-175.9
Hodgkin's Lymphoma 201.00-201.98
Multiple Myeloma 203.00-203.02, 203.10-203.12, 203.80-203.82
Chronic Myelocytic Leukemia 205.10, 205.11, 205.12
Endometrial 182.0-182.8
Ovarian 183.0-183.9
Peritoneal cancer 158.0-158.9
Prostate 185
Testes 186.0-186.9
Waldenstrom Macroglobulinemia 273.3
Non-Hodgkin's Lymphoma (NHL) 200.00-200.88, 202.00-202.98
Bone marrow ablation or preparation of a peripheral stem cell transplant for a Medicare covered transplant. V42.81, V42.82


34. Mitoxantrone (Novantrone) (J9293)
Acute non-lymphocytic leukemia 205.00-205.02, 205.10-205.12, 205.20-205.22, 205.30-205.32, 205.80-205.82, 205.90-205.92, 206.00-206.02, 206.10-206.12, 206.20-206.22, 206.80-206.82, 206.90-206.92, 207.00-207.02, 207.10-207.12, 207.20-207.22, 207.80-207.82, 208.00-208.02
Acute Lymphocytic Leukemia 204.00, 204.01, 204.02
Chronic Lymphocytic Leukemia 204.10, 204.11, 204.12
Breast 174.0-175.9
Liver 155.0-155.2
Multiple Myeloma 203.00, 203.01, 203.02, 203.10, 203.12
Nasopharynges 147.0-147.9
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Prostate 185
Bladder 188.0-188.9, 233.7
Ureter 189.1, 189.2
Hodgkin's Lymphoma 201.00-201.98
Multiple Sclerosis 340

35. Nelarabine (Aarron) (J9261) 50 mg
Acute lymphoblastic Leukemia 204.00, 204.01, 204.02
Lymphoblastic lymphoma, T-cell 200.10-200.18

36. Octreotide, Depot Form for Intramuscular Injection, 1 mg.(Sandostatin LAR Depot) (J2353)
Acromegaly 253.0
Carcinoid Syndrome 259.2
Neuroendocrine tumors 209.00-209.03, 209.10-209.17, 209.20-209.29, 209.30, 209.70
Pancreas 157.0-157.9
Vasoactive intestinal peptide tumors (VIPomas) 159.0
(For the control of diarrhea associated with VIPomas)
Chemotherapy induced diarrhea 787.91
Angiodysplasia of intestine with hemorrhage 569.85

37. Oxaliplatin (Eloxatinâ„¢) 0.5 mg (J9263)
Colorectal Cancer 153.0-154.8
Esophageal 150.0-150.9
Intrahepatic bile ducts 155.1
Biliary tract /Extrahepatic bile Ducts 156.0-156.9
Ovarian- when used as single agent recurrence therapy for low-grade or focal recurrences after a disease free interval of more than 6 months. Or for recurrence therapy as a single agent for progressive or stable disease on primary chemotherapy 183.0-183.9
Testes 186.0, 186.9
Pancreas 157.0-157.3, 157.8, 157.9
Small intestine 152.0-152.9
Stomach 151.0-151.9
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Chronic Lymphoid Leukemia 204.10, 204.12

38. Paclitaxel (Taxol) 30mg (J9265)
Bladder 188.0-188.9, 233.7
Kidney 189.0
Ureter 189.1, 189.2
Breast 174.0-175.9
Cervical 180.0-180.9
Endometrial 182.0-182.8
Esophageal 150.0-150.9
Gastric 151.0-151.9
Head and neck 140.0-149.9, 160.0-161.9, 195.0
Kaposi's Sarcoma 176.0-176.9
Lung 162.2-162.9
Malignant Pleural effusion 197.2
Metastatic Melanoma 172.0-172.9
Ovary/Fallopian tube 183.0-183.9
Peritoneal cancer 158.0-158.9
Prostate 185
Carcinoma of unknown primary 199.0, 199.1
Testes 186.0-186.9
Head and Neck Cancer 173.0, 196.0, 235.1, 235.6
Angiosarcoma 171.0, 171.3, 171.5, 171.9
Thymus 164.0
Basal cell skin cancer 173.01, 173.11, 173.21, 173.31, 173.41, 173.51, 173.61, 173.71, 173.81, 173.91

39. Paclitaxel protein-bound particles, 1 mg (Abraxaneâ„¢) (J9264)
Breast 174.0-175.9
Non-Small cell lung cancer 162.2-162.9
Malignant neoplasm of specified parts of peritoneum 158.8
Ovarian- Recurrence therapy as a single agent for - progressive, stable or persistent disease on primary chemotherapy, or relapse after complete remission following primary chemotherapy, or stage II-IV disease showing partial response to primary treatment
183.0-183.9


40. Panitumumab (Vectibix), 10 mg (J9303)

Colorectal cancer 153.0-154.8

Panitumumab (Vectibixâ„¢) is indicated for the treatment of metastatic colorectal carcinoma. Patient must not have K-RAS mutation. Panitumumab is a recombinant human monoclonal antibody. If the patient has disease progression on an Epidermal Growth Factor Receptor (EGFR) monoclonal antibody, it would not be appropriate to use this drug.

41. Pentostatin (Nipent) 10 mg (J9268)
Hairy Cell Leukemia 202.40-202.48
Acute Lymphocytic Leukemia 204.00, 204.01, 204.02
Prolymphocytic Leukemia 204.90, 204.91, 204.92
Chronic Lymphocytic Leukemia 204.10, 204.11, 204.12
Cutaneous T-Cell Lymphomas, Mycosis Fungoides, Sézary's Disease 202.00-202.98

42. Pegaspargase (Oncaspar) per single dose vial (J9266)
(When patient has developed a hypersensitivity to native forms of L-asparaginase)
Acute lymphocytic leukemia 204.00, 204.01, 204.02

43. Pemetrexed Disodium (Alimta TM), 10 mg (J9305)
Mesothelioma For the treatment of patients with malignant pleural mesothelioma whose disease is either unresectable or who are otherwise not candidates for curative surgery. 163.0-163.9
Non-Small Cell Lung Cancer 162.2-162.9
Ovarian Cancer-Preferred single-agent recurrence therapy, if platinum resistant, for progressive or stable disease on primary chemotherapy, stage II-IV disease showing partial response to primary treatment 183.0-183.9
Previously Untreated cervical cancer 180.0-180.9
Bladder cancer-as second-line therapy as a single agent for metastatic disease 188.0-188.9, 233.7
Malignant neoplasm of specified parts of peritoneum 158.8

44. Porfimer sodium (Photofrin), 75 mg (J9600)
Esophagus 150.0-150.9; 530.85
Lung 162.2-162.9

45. Pralatrexate (Folotyn) 1 mg (J9307)
Relapsed or refractory peripheral T-cell lymphoma (PTCL) 200.60-200.68, 202.10-202.18, 202.70-202.78, 202.80-202.88

46. Romidepsin (Istodax) 1 mg (J9315)
Cutaneous T- cell lymphoma (CTCL) in patients that have received at least one prior systemic therapy (202.00-202.98). (Effective 11/05/2009)

Peripheral T-cell lymphoma (PTCL) in patients that have received at least one prior therapy. (202.70-202.78) (Effective FDA approval date-06/16/2011

47. Streptozocin (Zanosar), 1 gram (J9320)
Acute Lymphocytic Leukemia 204.00, 204.01, 204.02
Carcinoid Tumors 209.00-209.29, 209.70-209.74, 259.2, 140.0-199.1
Colorectal 153.0-154.8
Hodgkin's Lymphoma 201.00-201.98
Lung 162.2-162.9
Melanoma 172.0-172.9
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Pancreas/ Islet Cell 157.0-157.9
Liver 155.0-155.2

48. Temsirolimus (Toriselâ„¢) 1 mg (J9330)
Advanced Renal Cell Carcinoma 189.0, 189.1

49. Teniposide (Vumon) 50 mg Q2017
Acute Lymphocytic Leukemia 204.00, 204.01, 204.02
Neuroblastoma 160.0-160.9, 194.0-194.9
Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98

50. Topotecan (Hycamtin) 0.1 mg (J9351)
Cervical Cancer 180.0-180.9
Endometrial cancer 182.0-182.8
Lung cancer 162.2-162.9
Ovarian Cancer 183.0-183.9
Myelodysplastic Syndrome 238.72-238.76
Chronic Myelocytic Leukemia 205.10, 205.11, 205.12
Peritoneal cancer 158.0-158.9
Primary central nervous system lymphoma-relapsed or refractory 200.50
Merkel Cell Carcinoma 209.31-209.36, 209.75

51. Valrubicin intravesical (Valstar) 200mg (J9357)
Bladder cancer 188.0-188.9, 233.7

52. Vinorelbine tartrate (Navelbine) per 10 mg (J9390)
Breast 174.0-175.9
Cervical Cancer 180.0-180.9
Lung (NSCLC) 162.2-162.9
Mesothelioma 163.0, 163.1, 163.8, 163.9
Ovary 183.0-183.9
Peritoneal cancer 158.0-158.9
Prostate 185
Soft Tissue Sarcomas 171.5, 171.9
Hodgkin disease-Second line treatment prior to autologous stem cell rescue in patients initially treated with chemotherapy alone or in combination with radiation therapy as a component of one of the following regimens: GVD or IGEV 201.50-201.58, 201.60-201.68, 201.70-201.78, 201.90-201.98


D. Not otherwise Classified Agents (NOC) (J3590, J9999, C9399)
1. Brentuximab vedotin (ADCETRISTM) (J9999) FDA approved 08/19/2011
- The treatment of patients with Hodgkin lymphoma after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates (201.00-201.98)
- The treatment of patients with systemic anaplastic large cell lymphoma after failure of at least one prior multi-agent chemotherapy regimen (200.60-200.68)

ASC and Hospital Outpatient Departments
Brentuximab vedotin (ADCETRISTM), 1mg (C9287)


2. Raltitrexed (Tomudex) (J9999/C9399)
Colorectal cancer 153.0-154.8


E. Monoclonal Antibodies that are useful in chemotherapeutic regimens:
1. Rituximab (Rituxan) 100 mg, (J9310)
Rituxan is indicated for the treatment of patients with CD20 positive, B-cell non-Hodgkin's lymphoma:

- Relapsed or refractory low-grade or follicular,
- first-line treatment of follicular in combination with cyclophosphamide, vincristine and prednisone (CVP),
-as single-agent maintenance therapy of follicular in patients achieving a complete or partial response to Rituxan in combination with first line chemotherapy,
- low grade in patients with stable disease or who receive a partial or complete response following first line treatment with CVP,
- Diffuse large cell in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or other anthracycline based chemotherapy.

Used in combination with methotrexate to reduce the signs and symptoms of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more Tumor Necrosing Factor (TNF) antagonists therapies.

Rituximab will be covered for retreatment of rheumatoid arthritis.

Status post stem cell transplant for those who develop reactivation of Epstein - Barr virus and are at high risk for Epstein-Barr virus-lymphoproliferative disease.

Non-Hodgkin's Lymphoma 200.00-200.88, 202.00-202.98
Acute Lymphoid Leukemia 204.00-204.02
Chronic Lymphocytic Leukemia 204.10-204.11, 204.12
Hodgkin's Lymphoma 201.40-201.48
Waldenstrom Macroglobulinemia 273.3
Idiopathic thrombocytopenia 287.30-287.39
Autoimmune hemolytic anemia 283.0
Rheumatoid Arthritis & retreatment 714.0-714.2
Post Stem cell transplant and Epstein Barr virus V42.82 and 075
Refractory chronic graft versus host disease 996.80-996.89 and 279.52
Acute refractory and relapsed refractory thrombotic thrombocytopenic purpura (TTP) due to immune-mediated ADAMTS-13 deficiency. 446.6
Wegener's granulomatosis 446.4
Post transplant lymphoproliferative disorder 996.80-996.89 and 238.77
Multicentric Castleman's disease associated with human herpesvirus infection in HIV-infected patients 785.6
Microscopic polyangiitis (MPA) (Effective-FDA approval date 04/19/11) 446.0
Dermatomyositis 710.3
Acquired hemophilia 286.52
Acquired coagulation factor deficiency 286.7
(effective 12/01/2011)
Polymyositis 710.4

2. Trastuzumab (Herceptin) 10 mg (J9355)
Patients must have a positive 2+ HER 2 and demonstrate amplification on the FISH test or a positive 3+ HER 2 test or a positive fish test.
Breast 174.0-175.9
Gastric Cancer -used in combination with systemic chemotherapy for the treatment of patients with advanced gastric cancer that is HER-2 positive as determined by a standardized method. 151.0-151.9
Esophageal -when used in combination with systemic chemotherapy for the treatment of patients with advanced esophageal or gastroesophageal junction adenocarcinoma that is HER-2-positive by a standardized method
150.0-150.9

3. Ofatumumab (Arzerra) 10 mg (J9302) effective 10/26/2009 FDA Approval date
Ofatumumab is covered for the treatment of Chronic Lymphocytic Leukemia (CLL) (204.10) that is refractory to fludarabine and Alemtuzumab or relapsed CLL (204.12).


F. Coverage of Cyclophosphamide (J9070) and Methotrexate (J9250, J9260) for indications other than oncologic diseases.

1. Cyclophosphamide (J9070)
a. Wegener's granulomatosis 446.4
b. Rheumatoid arthritis 714.0
c. Systemic Lupus Erythematosus 710.0
d. Systemic sclerosis 710.1
e. Vasculitis 447.6
f. Polyarteritis nodosa 446.0
g. Multiple sclerosis 340
h. Nephrotic syndrome in children 581.0-581.9
i Immune thrombocytopenia (severe) 287.30-287.39
j. Autoimmune hemolytic anemia (severe) 283.0
k Multifocal motor neuropathy 356.4
l. Cryoglobulinemia/Macroglobulinemia 273.0-273.3
m. Castleman Disease 785.6

2. Methotrexate (J9250, J9260)
a. Rheumatoid arthritis (severe) 714.0
b. Psoriasis (severe) 696.1
c. Psoriatic arthritis (severe) 696.0
d. Reiter's Disease 711.10-711.19
e. Lupus glomerulonephritis 710.0, 583.81
f. Temporal arteritis 446.5
g. Still's Disease 714.2, 714.30
h. Autoimmune bullous pemphigoid (severe) 694.5
i. Pulmonary interstitial fibrosis 516.30, 516.31, 516.32, 516.33, 516.36, 516.37
j. Severe polymyositis 710.4
k. Vasculitis 447.6
l. Ectopic Pregnancy 633.00-633.81, 633.90, 633.91
m. Unspecified Inflammatory polyarthropathy 714.9
n. Ankylosing spondylitis 720.0

G. Requests for off label coverage consideration should be submitted via the LCD reconsideration process described on our website http://www.wpsmedicare.com/ or submit a request with a copy of the compendia documenting the medically accepted category or narrative and or peer reviewed literature that is published in a CMS accepted journal supporting its use via e-mail to policycomments@wpsic.com


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.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient

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.

Note: We have identified the Type of Bill (TOB) and Revenue Center (RC) codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all TOB and/or RC codes listed. CPT/HCPCS codes are required to be billed with specific TOB and RC codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual, for further guidance.

0250 Pharmacy - General Classification
0259 Pharmacy - Other Pharmacy
0636 Pharmacy - Drugs Requiring Detailed Coding

CPT/HCPCS Codes

See section "Indications and Limitations of Coverage"

XX000Not Applicable

ICD-9 Codes that Support Medical Necessity

Note: ICD-9 codes must be coded to the highest level of specificity.
See section "Indications and Limitations of Coverage"

XX000Not Applicable

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity
Not applicable, See billing and coding guidelines for denial reasons
XX000 Not Applicable

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

Diagnoses that DO NOT Support Medical Necessity
Not applicable

General Information

Documentations Requirements
The medical record should include the disease being treated with the name and dosage of the drug being administered. Medical Records should be made available upon Carrier's request.

Appendices

Utilization Guidelines
Coverage for medication is based on the patient's condition, the appropriateness of the dose and route of administration, based on the clinical condition and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition. The drug must be used according to the indication and protocol listed in the accepted compendia ratings listed in this LCD.

Sources of Information and Basis for Decision
Compendia Based Drug Bulletin, CAC - Each Revision MCM 2049.2; Pharmaceutical inserts; USPDI update Vol. 1 & 2; Corr-00-06-627; PM AB-02-072,

Wormald R, Wilkins MR, Bunce C. Post-operative 5-Fluorouracil for glaucoma surgery (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, LTd.

Carmen J. Allegra, J. Milburn Jessup, et al; American Society of Clinical Oncology Provisional Clinical Opinion: Testing for KRAS Gene Mutations in Patients With Metastatic Colorectal Carcinoma to Predict Response to AntiEpidermal Growth Factor Receptor Monoclonal Antibody Therapy; Journal of Clinical Oncology, 2009 Feb 2

Dastur Yk,, et. al The role of initial 5-Fluorouracil trabeculectomy in primary glaucoma. Journal of Postgraduate Medicine, 1994 Volume 40 issue 4, page 197-201

Hagop Kantarjian, M.D. Yasuhiro Oki, M.D. Guillermo Garcia-Manero, M.D., Xuelin Huang, Ph.D., et al. Results of a Randomized Study of Three Schedules of Low-Dose Decitabine in Higher Risk Myelodysplastic Syndrome and Chronic Myelomonocytic Leukemia. Blood First Edition Paper, prepublished online August 1, 2006; DOI 10.1182/blood-2006-05-021162

Jolien Tol, M.D., Miriam Koopman, M.D., et al; "Chemotherapy, Bevacizumab, and Cetuximab in Metastatic Colorectal Cancer" New England Journal of Medicine, 2009, February, VOL 360 NO 5

NCCN

Advisory Committee Meeting Notes
Wisconsin 09/26/2008
Illinois 09/17/2008
Michigan 09/24/2008
Minnesota 09/11/2008
Iowa 10/16/2008
Kansas 10/16/2008
Missouri 10/17/2008
Nebraska 10/16/2008


This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from hematology, oncology, family practice and other specialties.

Start Date of Comment Period
10/18/2008
End Date of Comment Period
12/03/2008
Start Date of Notice Period
09/01/2011

Revision History Number
X

Revision History Explanation
12/01/2010-Added 204.00-204.12 to J9310 and added 173.1-173.9 to J9265, Updated NOC listing (J9999/C9399) Ofatumumab is covered for the treatment of CLL (204.10) that is refractory to fludarabine and Alemtuzumab or relapsed CLL (ICD 204.12).

11/01/2010- Added 996.80-996.89 and 238.77 to J9310

10/01/2010-Added J0641 to Section B, October 2010 Integrated Outpatient Code Editor (I/OCE) update Added C9273-Sipuleucel-T, per infusion and changed will develop for records to may develop. Added ICD-9 codes 182.0-182.8 to J9171

09/01/2010- Added 171.0-171.9 to J9001, added 170.0-170.9 to J9206, added Cabazutaxel (J9999) and ICD-9 code 185 effective 07/17/10- FDA approval date.

08/01/2010- Added Provenge (sipuleucel-T) (J3590/C9399) effective 04/29/10- FDA approval date & added 446.4 to J9310 effective 07/01/10

07/01/2010- Added V42.82 to J9185, Added 163.0, 163.1, 163.8, 163.9 to J9390

06/01/2010- Removed progression on or following fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy regimens from J9303 as it will be covered as first line therapy for the treatment of Colorectal cancer & added 446.6 to J9310, added 189.0 to J9171.

05/01/2010-Added 164.0 to J9265; 152.0-152.9 to J9263, Added 202.10 -202.18, 202.20-202.28 to J9010, added 205.10, 205.12 to J0894, added 189.1, 189.2 to J9171, added V42.82 and 075,
996.80-996.89 and 279.52 to J9310; added or a positive fish test to J9355.


04/01/2010- Added ICD-9 710.1 to J9070-J9097; Typo corrected in section C. #7

03/01/2010- Typo corrected- J9062 Cisplatin changed to 50 mg.

02/01/2010- Added 150.0-150.9 to J9355; added 188.0-188.9, 233.7 to J9305; added 209.00-209.03, 209.10-209.17, 209.20-209.29, 209.30, 209.70 to J2353.

01/01/2010-Added 171.0, 171.3, 171.5, 171.9 to J9265; added 201.50-201.58, 201.60-201.68, 201.70-201.78, 201.90-201.98 to J9390 & J9001, added 199.0 & 199.1 to J9201; added 273.3 to J9041; Annual code updates Added J9171, deleted J9170; J9015 effective date of ICD-9 code 190.9 changed to 05/16/09;

*12/01/09-Added 277.30 to J9041 & 785.6 to J9070-J9097

*Published 11/01/09 Added Pralatrexate (Folotyn) (J9999/C9399) & 202.70-202.78 effective 9/24/09 FDA approval date; added 190.9 to J9015-Effective 09/01/09 ;

*Published 10/01/09 added 180.0-180.9 to J9305, Added 151.0-151.9 to J9355, added 183.0-183.9 and 186.0, 186.9 to J9263, and added 180.0-180.9 to J9305. Language changes to J9055 and J9303;

09/18/2009 *Published 09/01/09 added 200.60-200.68, 202.70-202.78, 202.80-202.88 to (J9041)

Published 08/01/09- added ICD-9 codes 156.0-156.9,157.0-157.3, 157.8, 157.9 to J9263, added 196.0 to J9055, added 273.3 to J9370, J9375, J9380, J9250 replaced 710.9 with 714.2 & 714.30 for Still's disease, J9390-added 171.5, 171.9, J9025 added 205.10, 205.12;

6/29/09 Removed contractor number 05392 because as of 8/1/09 E MO will join with the current number for W MO

*Effective 05/16/09 added ICD-9 codes 183.0-183.9 to J9305 and 200.50 to J9350, J9245 corrected typo for range 203.10-203.12

Clarification of the need for K-RAS test for treatment of colorectal cancer for J9055, Added 205.01 and 205.02 to J9025, 205.12 added to J9213, Added 162.2-162.9 to J9264, added 200.00-200.88, 202.00-202.98 to J9263 added 182.0-182.8 to J9350 effective 05/16/09;

Effective 5/16/09-Added AML ICD-9 codes 205.00, 205.01, and 205.02 to J0894 Decitabine (Dacogen)

8/1/2010 - The description for Bill Type Code 11 was changed
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 18 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 Revenue code 0250 was changed
8/1/2010 - The description for Revenue code 0259 was changed
8/1/2010 - The description for Revenue code 0636 was changed

01/01/2011-HCPCs code update- Added J9302, J9307, J9351, C9276;Removed deleted codes J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9110, J9140, J9290, J9291, J9350, J9375, J9380; Added ICD-9 codes 209.31-209.36, 209.75 to J9351, added 785.6 to J9310; Added 158.8 to J9305 & J9264; added 158.0, 158.8, 158.9 171.0-171.9 to J9035, added 174.0-174.9, 175.0-175.9 to Eribulin mesylate (Halaven) (J9999)

02/01/2011-removed deleted code J9062- effective 01/01/2011

03/01/2011- Added 182.0 to J9001, added 156.2 & 156.8 to J9201; added 200.60-200.68, 202.10-202.18, 202.80-202.88 to J9307, added 174.0-175.9 to J9206; added 273.3 to J9033; added new FDA approved indication to J9310 -as single-agent maintenance therapy of follicular in patients achieving a complete or partial response to Rituxan in combination with first line chemotherapy.

04/01/2011- added 203.00-203.02 to J9033

05/01/2011- Added 170.0-170.9 to J9171 & J9201; J9264 added 183.0-183.9, Added J9999-Ipilimumab-
172.0-172.9- effective 03/25/11 (FDA approval date)

07/01/2011- Add new code Q2043 & removed C9273; Added 155.1 & 204.10, 204.12 to J9263; Added 720.0 to J9250, J9260

08/01/2011-Added 201.40-201.48 to J9310, added 179, 180.0, 182.0-182.8 to J9201; added 200.00-200.88, 202.00-202.98 and V42.81, V42.82 to J9245; added J9315 & 202.00-202.98 effective 11/05/2009 -FDA approval date & 202.70-202.78-effective 06/16/2011 -FDA approval date; added As a single agent or in combination with irinotecan after first progression except in patients receiving capecitabine or fluorouracil and leucovorin with bevacizumab to J9055; Moved information on Q2043 Sipuleucel-T (Provenge®) from the LCD to the billing and coding guidelines and included information from the new NCD -Section 110.22 Autologous Cellular Immunotherapy Treatment (Effective June 30, 2011)(CR 7431-Transmittal 133 ) and Claims Processing Manual Change Request 7431-transmittal 2254.

09/01/2011-J9201-added 156.1, 156.2, 156.8, 156.9; Added 446.0 to J9310 effective 04/19/11-FDA approval date, J9320-added 209.00-209.29, 209.70-209.74

10/01/2011-ICD-9 code update-Added 365.70, 365.71, 365.72, 365.73 to J9190, Added 173.00-173.99 to J9213, J9214, J9040, J9045, J9050, J9060, J9070; Added 516.30-516.37 to J9250, J9260, Added 173.01, 173.11, 173.21, 173.31, 173.41, 173.51, 173.61, 173.71, 173.81, 173.91, 189.0 to J9265 & removed 239.2, added 516.30, 516.31, 516.32, 516.33, 516.36, 516.37 to J9250, J9260, added 173.00-173.99 to J9040, J9045, J9050, J9060, J9070 & added (J9999/C9399) Brentuximab vedotin (ADCETRISTM ) effective 08/19/2011-FDA approval date for - The treatment of patients with Hodgkin lymphoma after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates (201.00-201.98) and for the treatment of patients with systemic anaplastic large cell lymphoma after failure of at least one prior multi-agent chemotherapy regimen (200.60-200.68)

12/01/2011- Added 710.3, 286.52 to J9310.

01/01/2012-2012 Code update: Removed deleted code C9276 & Added C9287, J9043, J9179, and J9228 & Removed J9999 & C9399 for drugs that now have a true 2012 HCPCs code.

02/01/2012-Article Added 286.7 to J9310- effective 12/01/2011

03/01/2012 Article posted- Added 173.02, 173.12, 173.22, 173.32, 173.42, 239.2, V10.83 to J9055. Added 203.80, 238.6 to J9041

04/01/2012- article posted-added 204.80, 204.82 to J9010; added 199.0, 199.1 to J9206, added 710.4 to J9310

Reason for Change
ICD9 Addition/Deletion

Related Documents
This LCD has no Related Documents.

LCD Attachments

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Page Last Updated: Tuesday, 03-Apr-2012 14:49:44 CDT