Revised - Updates - Policy - Part B

Revised Policies

The following are revised policies. To view the new policies on the WPS Medicare Website, use the left hand navigation to go to the Local Policies (LCD). Be sure to note the effective date of the revision, as the revision will not appear in the Active policy until the effective date. Prior to the effective date, the revision can be found by selecting the link "Display Future Effective Documents" within the CMS Medicare Coverage Database (MCD) .

September 2010

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 09/01/10 AND ON THE WPS MEDICARE WEBSITE 09/06/10.

Policy Title	MCD Policy #	WPS Policy #	Effective Date
Botulinum Toxin Type A & Type B	L28555	INJ-018	09/01/2010
09/01/2010, six, added ICD-9 codes 596.54, 596.55 when billed with CPT code 53899, 64614 or 64647 with an effective date of 05/16/2009.
Chemotherapy Drugs and their Adjuncts	L28576	HONC-010	See below
Indications and Limitations of Coverage and/or Medical Necessity C. The following drugs are covered for the following indications -effective 09/01/2010 18. Doxorubicin Hydrochloride, all lipid formulations, 10 mg (Doxil) (J9001) Malignant neoplasm of connective and other soft tissue-trunk 171.0-171.9 28. Irinotecan (Camptosar) 20 mg (J9206) Ewing's Sarcoma 170.0-170.9 D. Not otherwise Classified Agents (NOC) (J3590, J9999, C9399) 3. Jevtana® (Cabazutaxel) (J9999/C9399) 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.
Human Granulocyte/Macrophage Colony Stimulating Factors	L30306	INJ-019	09/01/2010
ICD-9 codes 202.00-202.08 have been added to the following indication. D. Indications for Sargramostim (Leukine ) (J2820): 2. Acceleration of myeloid recovery in patients with non-Hodgkin's lymphoma (NHL), acute lymphoblastic leukemia (ALL) and Hodgkin's disease undergoing autologous bone marrow transplantation (BMT). Indicate this by coding the BMT (V42.81) and NHL (202.00-202.08, 202.80-202.88) or ALL (204.00, 204.02) or Hodgkin's disease (201.40-201.98).
Psychiatry and Psychology Services	L30489	PSYCH-014	09/01/2010
Added ICD-9 278.01 Morbid Obesity

August 2010

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 08/01/10 AND ON THE WPS MEDICARE WEBSITE 08/06/10.

Policy Title	MCD Policy #	WPS Policy #	Effective Date
Bariatric Surgery for Morbid Obesity	NA	GSURG-042	01/01/2010
08/01/2010: Added in the Billing and Coding Guidelines, under Non-Covered Bariatric Surgery Procedures the following statements that have an asterisk: WPS Medicare will process non-covered outpatient bariatric surgery claims according to the conditions outlined below: CPT procedure code 43842 will be denied when used for: open vertical banded gastroplasty. CPT NOC code 43999 will be denied when used for: Laparoscopic vertical banded gastroplasty. Open sleeve gastrectomy. Laparoscopic sleeve gastrectomy. Open adjustable gastric banding. CPT code 43775 was added to the 2010 CPT/HCPCS Codes for a laparoscopic sleeve gastrectomy. CPT code 43775 is considered noncovered and will be denied based on CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 100.1.
Bone Mass Measurement Coding and Billing Guidelines	L28527	MS-004	08/01/2010
*08/01/2010, Reinstated ICD-9-CM codes V58.65, V58.69 and V67.51 for the purpose of reporting conditions described under Indications and Limitations, section B. Effective from 03/18/2009
Chemotherapy Drugs and their Adjuncts	L28576	HONC-010	See below
Indications and Limitations of Coverage and/or Medical Necessity D. Not otherwise Classified Agents (NOC) (J3590, J9999, C9399) Provenge® (sipuleucel-T) (J3590/C9399) effective 04/29/10 FDA approval date This is an autologous cellular immunotherapy indicated for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer (185). Patients receiving sipuleucel-T infusions will have been to a pheresis center for leukapheresis. The individual patient lymphocytes will be used to manufacture a patient-specific medication (autologous cellular therapy), which when infused back into the patient (usually three days after leukapheresis) will stimulate a positive immunogenic response against his prostate cancer. Provenge is administered as three infusions, generally two weeks apart. Provenge should be administered via intravenous infusion over a period of approximately 60 minutes. The patient cannot be getting simultaneous chemotherapy and should not be getting immunosuppressive therapy. We will develop for documentation on the first infusion. Documentation should include: Documentation in the chart would demonstrate the patient was asymptomatic or minimally symptomatic and had metastatic castrate resistant (hormone refractory) disease. Evidence of metastases to soft tissue or bone Testosterone levels < 50ug or below lowest level of normal Two sequential rising PSA levels obtained 2-3 weeks apart or other evidence of disease progression We will only develop for the first infusion. Medicare will allow a maximum of three infusions per lifetime. E. Monoclonal Antibodies that are useful in chemotherapeutic regimens: Effective 07/01/2010: Rituximab (Rituxan) 100 mg, (J9310) Wegener's granulomatosis 446.4
Flow Cytometry	L30161	PATH-016	11/16/2009
ICD-9 Codes that Support Medical Necessity The following information was in error: The coding is corrected as follows: 285.6 replaces 285.9 The correct codes for the policy are: 285.9 and 785.6
Human Granulocyte/Macrophage Colony Stimulating Factors	L30306	INJ-019	08/01/2010
We have clarified our coverage on dose intervals: Utilization Guidelines Dose dense chemotherapy treatment schedules and other chemotherapy regimens with cycle intervals of less than 3 weeks, such as those with 2 week intervals, will be allowed where literature supports its use.
Injection List	NA	Injection list	06/22/2010
Ranibizumab (Lucentis™) (J2778) is covered for the treatment of Macular edema following retinal vein occlusion (RVO). Code macular edema 362.83 and 362.35, Central retinal vein occlusion (CRVO) or 362.36, Venous tributary (branch) occlusion (BRVO). Effective 06/22/10-FDA approval date
Magnetic Resonance Angiography (MRA) of the Head and Neck, Chest, Abdomen & Pelvis, Lower Extremities	L26696	RAD-523	06/07/2010
06/07/2010, As described in CR 7040, Provisions of MRA NCD section 220.3 C of the NCD manual merged into section 220.2, effective 06/07/2010. RAD-023 is a WPS copy of the NCD maintained for the purpose of providing coding and billing guidelines.

July 2010

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 07/01/10 AND ON THE WPS MEDICARE WEBSITE 07/06/10.

Policy Title	MCD Policy #	WPS Policy #	Effective Date
Bariatric Surgery for Morbid Obesity	NA	GSURG-042	08/01/2010
08/01/2010: Added instructions under Coding Information. Instructions for claims submitted to the carrier or Part B MAC: Claims for CPT codes 43644, 43645, 43770, 43845, 43846, and 43847 are payable under Medicare Part B in place of service inpatient hospital (21). Claims for an adjustment of a gastric restrictive device should be reported using CPT code 43999 with the statement "Adjustment of gastric restrictive device" in item 19 of the CMS 1500 claim form or electronic equivalent. An adjustment of the gastric band (CPT code 43999) or an E&M service is not payable within the global period of the surgery when these services are performed by the same physician who performed the surgery. An E&M and the adjustment of a gastric band (CPT code 43999) will only be allowed on the same day if there was a significantly separate service provided. The modifier -25 should be appended to the E&M code to indicate the E&M service was a significantly separate service.
Chemotherapy Drugs and their Adjuncts	L28576	HONC-010	07/01/2010
CPT/HCPCS Codes Indications and Limitations of Coverage and/or Medical Necessity 20. Fludarabine Phosphate (Fludara) 50 mg (J9185) Peripheral stem cell transplant V42.82 47. Vinorelbine tartrate (Navelbine) per 10 mg (J9390) Mesothelioma 163.0, 163.1, 163.8, 163.9
Epidural and Transforaminal Epidural Injections	L30481	NEURO-007	04/15/2010
Anti-spasmodic drugs administered intrathecally (e.g., baclofen) to treat chronic intractable spasticity are addressed in the Infusion Pump NCD Pub. 100-3 Sec. 280.14. The CPT description of procedure codes 62310, 62311, 62318 and 62319 include anesthetic, antispasmodic, opioid, steroid, other solution; therefore the spasticity conditions are included in this LCD. ICD-9 codes 340, 342.10-342.12, 343.0-343.9, 344.00-344.5, 728.85, and 781.0 were added effective 04/15/2010.
Flow Cytometry	L30161	PATH-016	11/16/2009
ICD-9 Codes that Support Medical Necessity The coding is corrected as follows: *285.6 replaces 285.9
Immune Globulins	L30147	INJ-012	07/01/2010
The following ICD-9 codes were added to the LCD: 694.4 pemphigus 694.5 pemphigoid 694.60 benign mucous membrane pemphigoid without ocular involvement 694.61 benign mucous membrane pemphigoid with ocular involvement 694.8 other specified bullous dermatoses Indications and Limitations of Coverage and/or Medical Necessity B. 29. Autoimmune mucocutaneous blistering disease is covered by a National Coverage Determination (See IOM Pub. 100-3: Medicare National Coverage Determination Manual Chapter 1, Part 4 Section 250.3) (694.4, 694.5, 694.60, 694.61, 694.8)
Podiatry Code List	N/A	N/A	N/A
The WPS medical director staff added the following procedure codes to the list of HCPCS codes approved as payable for podiatrists. CPT code 89060 - Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) CPT code 97112 - Neuromuscular re-education of movement, balance, coordination etc, will be added to the Podiatry list. Note: CPT code 97112 may be billed when personally performed by a physician or a physical therapist. It may not be billed under the 'incident to' benefit when the service is performed by an employee who is not a physical therapist.
Psychiatry and Psychology Services	L30489	PSYCH-014	3/18/2010
CPT code 90870 removed from this LCD. See L30493, Electroconvulsive Therapy, PSYCH-025 for services on and after 07/16/2010.
Psychiatry and Psychology Services	L30489	PSYCH-014	07/01/2010
*Documentation: The medical record must document the conditions described under "description" relative to CPT codes 90846, 90847 and 90849.Documentation must be available and will be requested prior to payment. If the claim does not indicate that document is available it will be denied. (underlined added to LCD to reinforce importance of documentation.) Added ICD-9 codes 296.11-296.15, 296.80-296.82, 304.71-304-72, 313.89, V62.84;

Page Last Updated: Monday, 30-Aug-2010 10:36:23 CDT