Local Coverage Article: Drugs and Biologicals - Chemotherapeutic Agents (A52701)

Transcription

1 Local Coverage Article: Drugs and Biologicals - Chemotherapeutic Agents (A52701) Contractor Information Contractor Name Cahaba Government Benefit Administrators, LLC Article Information General Information Article ID A52701 Original ICD-9 Article ID A48896 Article Title Drugs and Biologicals - Chemotherapeutic Agents AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or Original Effective Date 10/01/2015 Revision Effective Date 10/01/2015 Revision Ending Date N/A Retirement Date N/A

2 not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Article Guidance Article Text: Chapter 15, Section 50.4 of the Medicare Benefit Policy Manual describes reasonableness and necessity of drugs and biologicals, including the approved use of a drug (50.4.1), the unlabeled use of a drug (50.4.2) and unlabeled use for anti-cancer drugs (50.4.5). This Contractor will cover unlabeled uses of FDA approved drugs and biologicals used in an anti-cancer chemotherapeutic regimen for a medically accepted indication based on Chapter 15, Section of the Medicare Benefit Policy Manual. This Contractor expects the use of chemotherapeutic agents will be reasonable and necessary. Automated payment edits will be implemented for select chemotherapeutics agents. Future edits will be implemented as needed upon review of data. The chemotherapeutic agents for which automated payment edits are implemented are listed below. Coverage of these agents will be allowed for indications meeting the criteria specified in the Benefit Policy Manual. The covered ICD-10 diagnosis codes are listed below each drug. All other ICD-10 codes will be denied. In addition, some of these drugs have indications for other than chemotherapy, and the appropriate ICD-10 codes are included. The list of covered ICD-10 codes will be updated as needed.

3 When appropriate compendia references the use of one of the chemotherapeutic agents listed in this Article as part of a combination therapy, the drug is only approved for use in such combinations, and the documentation should reflect, and be specific about, the use of the additional combination therapy drugs. SEE BELOW FOR LIST OF CHEMOTHERAPEUTIC AGENTS AND ALLOWED ICD- 10 CODES 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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. N/A 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 article 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 article should be assumed to apply equally to all Revenue Codes. N/A The Revenue Codes Information Table Not Applicable CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes:

4 CPT/HCPCS Codes Information Table J9025 J9035 J9041 J9045 J9055 J9171 J9201 J9206 J9263 J9264 J9293 J9305 J9310 J9351 J9355 Q2049 Q2050 INJECTION, AZACITIDINE, 1 MG INJECTION, BEVACIZUMAB, 10 MG INJECTION, BORTEZOMIB, 0.1 MG INJECTION, CARBOPLATIN, 50 MG INJECTION, CETUXIMAB, 10 MG INJECTION, DOCETAXEL, 1 MG INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG INJECTION, IRINOTECAN, 20 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, PEMETREXED, 10 MG INJECTION, RITUXIMAB, 100 MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, TRASTUZUMAB, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, IMPORTED LIPODOX, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWISE SPECIFIED, 10MG s that are Covered Group 1 Paragraph: Azacitidine (Vidaza ) (J9025) Group 1 Codes: Show entries for Group 1 s that are Covered: Group 1Codes C88.8 Other malignant immunoproliferative diseases C C Opens Acute myeloblastic leukemia, not having achieved remission - Chronic in a new myeloid leukemia, BCR/ABL-positive, in relapse C C92.A2 - Acute promyelocytic leukemia, not having achieved remission - Acute myeloid leukemia with multilineage dysplasia, in relapse C C Opens Acute panmyelosis with myelofibrosis not having achieved remission - in a new Myelodysplastic disease, not classified D D Opens Refractory anemia without ring sideroblasts, so stated - Refractory in a new anemia with excess of blasts 2

5 D46.4 Refractory anemia, unspecified D46.9 Myelodysplastic syndrome, unspecified D46.A - D46.C - Opens Refractory cytopenia with multilineage dysplasia - Myelodysplastic in a new syndrome with isolated del(5q) chromosomal abnormality D46.Z Other myelodysplastic syndromes D47.1 Chronic myeloproliferative disease D47.3 Essential (hemorrhagic) thrombocythemia D47.9 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue D D Opens Constitutional (pure) red blood cell aplasia - Other constitutional in a new aplastic anemia D D Antineoplastic chemotherapy induced pancytopenia - Myelophthisis D61.9 Aplastic anemia, unspecified D D Opens in Hereditary sideroblastic anemia - Other sideroblastic anemias a new Showing 1 to 17 of 17 entries in Group 1 Group 2 Paragraph: (L34303) Bevacizumab (Avastin ) (J9035) Group 2 Codes: Show entries for Group 2 s that are Covered: Group 2Codes C17.8 Malignant neoplasm of overlapping sites of small intestine C C Opens in Malignant neoplasm of cecum - Malignant neoplasm of overlapping a new sites of rectum, anus and anal canal C33 - C Opens in a Malignant neoplasm of trachea - Malignant neoplasm of unspecified new part of left bronchus or lung C47.0 Malignant neoplasm of peripheral nerves of head, face and neck C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck C C Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast C53.0 Malignant neoplasm of endocervix C C Opens in Malignant neoplasm of endometrium - Malignant neoplasm of fundus a new uteri C54.9 Malignant neoplasm of corpus uteri, unspecified

6 C C Opens in Malignant neoplasm of right ovary - Malignant neoplasm of uterine a new adnexa, unspecified C C Opens in Malignant neoplasm of right kidney, except renal pelvis - Malignant a new neoplasm of unspecified renal pelvis C C Opens in Malignant neoplasm of cerebrum, except lobes and ventricles - a new Malignant neoplasm of brain, unspecified Z85.00 Personal history of malignant neoplasm of unspecified digestive organ Z Personal history of other malignant neoplasm of large intestine Z Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus Z85.3 Personal history of malignant neoplasm of breast Showing 1 to 16 of 16 entries in Group 2 Group 3 Paragraph: Bortezomib (Velcade ) (J9041) Group 3 Codes: Show entries for Group 3 s that are Covered: Group 3Codes C C Diffuse follicle center lymphoma, unspecified site - Diffuse follicle center lymphoma, extranodal and solid organ sites C C Small cell B-cell lymphoma, unspecified site - Mantle cell lymphoma, extranodal and solid organ sites C C Other non-follicular lymphoma, unspecified site - Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites C84.40 Peripheral T-cell lymphoma, not classified, unspecified site Peripheral T-cell lymphoma, not classified, extranodal and solid organ C84.49 sites C C Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites C84.A0 - C84.Z9 - Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites C C Opens Unspecified B-cell lymphoma, unspecified site - Immunoproliferative in a new small intestinal disease

7 C C Opens Other malignant immunoproliferative diseases - Plasma cell leukemia in a new not having achieved remission C C Plasma cell leukemia in relapse - Solitary plasmacytoma in relapse Other specified neoplasms of uncertain behavior of lymphoid, D47.Z9 hematopoietic and related tissue Showing 1 to 11 of 11 entries in Group 3 Group 4 Paragraph: Carboplatin (Paraplatin) (J9045) Group 4 Codes: Show entries for Group 4 s that are Covered: Group 4Codes C C Opens Malignant neoplasm of external upper lip - Malignant neoplasm of in a new stomach, unspecified C21.2 Malignant neoplasm of cloacogenic zone C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal C C37 - Opens in Malignant neoplasm of nasal cavity - Malignant neoplasm of thymus a new C38.4 Malignant neoplasm of pleura C C Opens Malignant melanoma of lip - Malignant melanoma of skin, unspecified in a new C C Opens Mesothelioma of pleura - Mesothelioma of peritoneum in a new C45.9 Mesothelioma, unspecified C C Opens Malignant neoplasm of specified parts of peritoneum - Malignant in a new neoplasm of overlapping sites of retroperitoneum and peritoneum C4A.60 - C4A.62 - Merkel cell carcinoma of unspecified upper limb, including shoulder - Merkel cell carcinoma of left upper limb, including shoulder C C Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast C C Opens Malignant neoplasm of endocervix - Malignant neoplasm of cervix uteri, in a new unspecified C C Opens Malignant neoplasm of endometrium - Malignant neoplasm of fundus in a new uteri C54.9 Malignant neoplasm of corpus uteri, unspecified

8 C C Opens Malignant neoplasm of right ovary - Malignant neoplasm of uterine in a new adnexa, unspecified C61 - C Opens Malignant neoplasm of prostate - Malignant neoplasm of left testis, in a new unspecified whether descended or undescended C C Opens Malignant neoplasm of right kidney, except renal pelvis - Malignant in a new neoplasm of bladder, unspecified C C Malignant neoplasm of unspecified retina - Malignant neoplasm of left retina C C Opens Malignant neoplasm of cerebrum, except lobes and ventricles - in a new Malignant neoplasm of brain, unspecified C C Malignant neoplasm of cortex of unspecified adrenal gland - Malignant neoplasm of unspecified part of left adrenal gland C76.0 Malignant neoplasm of head, face and neck C C Secondary malignant neoplasm of unspecified lung - Secondary malignant neoplasm of left lung C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum C C C C C7A.1 C7A.8 C C Opens in a new C C C C C84.A0 - C84.Z9 - C C C88.4 Secondary malignant neoplasm of unspecified urinary organs - Secondary malignant neoplasm of other urinary organs Secondary malignant neoplasm of unspecified ovary - Secondary malignant neoplasm of left ovary Malignant poorly differentiated neuroendocrine tumors Other malignant neuroendocrine tumors Disseminated malignant neoplasm, unspecified - Malignant (primary) neoplasm, unspecified Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-cell proliferations Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

9 C C C C Opens in a new Hairy cell leukemia not having achieved remission - Hairy cell leukemia, in relapse Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis - Sarcoma of dendritic cells (accessory cells) Malignant neoplasm of lymphoid, hematopoietic and related tissue, C96.9 unspecified C96.A - C96.Z - Opens Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, in a new hematopoietic and related tissue D D Carcinoma in situ of unspecified bronchus and lung - Carcinoma in situ of left bronchus and lung D D Opens Melanoma in situ of lip - Melanoma in situ, unspecified in a new D09.0 Carcinoma in situ of bladder D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung Showing 1 to 41 of 41 entries in Group 4 Group 5 Paragraph: Cetuximab (Erbitux ) (J9055) Group 5 Codes: Show entries for Group 5 s that are Covered: Group 5Codes C C Opens in a Malignant neoplasm of external upper lip - Malignant neoplasm of new overlapping sites of lip, oral cavity and pharynx C C Opens in a Malignant neoplasm of cecum - Malignant neoplasm of overlapping new sites of rectum, anus and anal canal C C Opens in a Malignant neoplasm of head of pancreas - Malignant neoplasm of new pancreas, unspecified C C Opens in a Malignant neoplasm of nasal cavity - Malignant neoplasm of new unspecified part of left bronchus or lung C Unspecified malignant neoplasm of skin of unspecified part of face C Unspecified malignant neoplasm of skin of nose C C Opens Unspecified malignant neoplasm of skin of other parts of face - in a new Basal cell carcinoma of skin of nose C C Opens Basal cell carcinoma of skin of other parts of face - Squamous cell in a new carcinoma of skin of nose C Squamous cell carcinoma of skin of other parts of face C Other specified malignant neoplasm of skin of unspecified parts of face

10 C Other specified malignant neoplasm of skin of nose C Other specified malignant neoplasm of skin of other parts of face C44.42 Squamous cell carcinoma of skin of scalp and neck C76.0 Malignant neoplasm of head, face and neck Showing 1 to 14 of 14 entries in Group 5 Group 6 Paragraph: Docetaxel (Taxotere ) (J9171) Group 6 Codes: Show entries for Group 6 s that are Covered: Group 6Codes C C Opens in Malignant neoplasm of external upper lip - Malignant neoplasm of a new stomach, unspecified C C Opens Malignant neoplasm of nasal cavity - Malignant neoplasm of in a new unspecified part of left bronchus or lung C C Opens Unspecified malignant neoplasm of skin of lip - Other specified in a new malignant neoplasm of skin of scalp and neck C C Opens Malignant neoplasm of peripheral nerves of head, face and neck - in a new Malignant neoplasm of unspecified site of unspecified male breast C53.0 Malignant neoplasm of endocervix C C Opens in Malignant neoplasm of isthmus uteri - Malignant neoplasm of uterine a new adnexa, unspecified C61 Malignant neoplasm of prostate C C Opens in Malignant neoplasm of right renal pelvis - Malignant neoplasm of a new urethra C76.0 Malignant neoplasm of head, face and neck C79.82 Secondary malignant neoplasm of genital organs C80.1 Malignant (primary) neoplasm, unspecified Showing 1 to 11 of 11 entries in Group 6 Group 7 Paragraph: Doxorubicin HCl Liposomal (Lipo-dox ) (Q2049); Doxorubicin HCl Liposomal (not otherwise specified) (Q2050) Group 7 Codes: Show entries for Group 7 s that are Covered:

11 Group 7Codes C45.1 Mesothelioma of peritoneum C C Opens in Kaposi's sarcoma of skin - Kaposi's sarcoma, unspecified a new C48.1 Malignant neoplasm of specified parts of peritoneum Malignant neoplasm of overlapping sites of retroperitoneum and C48.8 peritoneum C C Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast C C Opens in Malignant neoplasm of isthmus uteri - Malignant neoplasm of uterine a new adnexa, unspecified C C Opens Diffuse follicle center lymphoma, unspecified site - Diffuse follicle in a new center lymphoma, extranodal and solid organ sites C C Opens Small cell B-cell lymphoma, unspecified site - Small cell B-cell in a new lymphoma, extranodal and solid organ sites C C Opens Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck - in a new Diffuse large B-cell lymphoma, extranodal and solid organ sites C C Opens Other non-follicular lymphoma, unspecified site - Sezary disease, in a new extranodal and solid organ sites C C Opens Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature in a new T/NK-cell lymphomas, unspecified, extranodal and solid organ sites C84.A0 - C84.Z9 - Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites C C Opens Unspecified B-cell lymphoma, unspecified site - Primary cutaneous in a new CD30-positive T-cell proliferations C C Opens Multiple myeloma not having achieved remission - Plasma cell in a new leukemia not having achieved remission C90.12 Plasma cell leukemia in relapse Showing 1 to 15 of 15 entries in Group 7 Group 8 Paragraph: Gemcitabine Hydrochloride (Gemzar ) (J9201) Group 8 Codes: Show entries for Group 8 s that are Covered: C C Opens in a new Group 8Codes Malignant neoplasm of pharynx, unspecified - Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

12 C16.9 Malignant neoplasm of stomach, unspecified C22.1 Intrahepatic bile duct carcinoma C23 - C Opens in Malignant neoplasm of gallbladder - Malignant neoplasm of pancreas, a new unspecified C33 - C37 - Opens in a Malignant neoplasm of trachea - Malignant neoplasm of thymus new C C Opens Malignant neoplasm of anterior mediastinum - Malignant neoplasm of in a new mediastinum, part unspecified C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura C45.1 Mesothelioma of peritoneum C45.9 Mesothelioma, unspecified C C Malignant neoplasm of peripheral nerves of head, face and neck - Malignant neoplasm of unspecified site of unspecified male breast C53.0 Malignant neoplasm of endocervix C C Opens Malignant neoplasm of isthmus uteri - Malignant neoplasm of uterine in a new adnexa, unspecified C58 Malignant neoplasm of placenta C C Malignant neoplasm of unspecified undescended testis - Malignant neoplasm of left testis, unspecified whether descended or undescended C C Opens in a new C68.9 Malignant neoplasm of urinary organ, unspecified C75.3 Malignant neoplasm of pineal gland C C Malignant neoplasm of right renal pelvis - Malignant neoplasm of bladder, unspecified Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck - Secondary malignant neoplasm of genital organs C80.1 Malignant (primary) neoplasm, unspecified C C C C C84.A0 - C84.Z9 - C C C88.4 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-cell proliferations Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

13 C C C C Opens in a new C96.9 C96.A - C96.Z - Hairy cell leukemia not having achieved remission - Hairy cell leukemia, in relapse Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis - Sarcoma of dendritic cells (accessory cells) Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue Z85.43 Personal history of malignant neoplasm of ovary Showing 1 to 29 of 29 entries in Group 8 Group 9 Paragraph: Irinotecan Hydrochloride (Camptosar ) (J9206) Group 9 Codes: Show entries for Group 9 s that are Covered: Group 9Codes C C Opens in a Malignant neoplasm of upper third of esophagus - Malignant new neoplasm of stomach, unspecified C17.8 Malignant neoplasm of overlapping sites of small intestine C C Opens in a Malignant neoplasm of cecum - Malignant neoplasm of overlapping new sites of rectum, anus and anal canal C C Opens in a Malignant neoplasm of head of pancreas - Malignant neoplasm of new pancreas, unspecified C33 - C Opens in a Malignant neoplasm of trachea - Malignant neoplasm of unspecified new part of left bronchus or lung C C Opens in a Malignant neoplasm of right ovary - Malignant neoplasm of new unspecified ovary C C Opens in a Malignant neoplasm of cerebrum, except lobes and ventricles - new Malignant neoplasm of brain, unspecified Showing 1 to 7 of 7 entries in Group 9 Group 10 Paragraph: Mitoxantrone Hydrochloride (Novantrone ) (J9293) Group 10 Codes: Show entries for Group 10 s that are Covered:

14 Group 10Codes C C Opens Liver cell carcinoma - Malignant neoplasm of liver, not specified as in a new primary or secondary C C Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast C61 C C C C C84.A0 - C84.Z9 - C C C88.4 C C C C C C C91.A0 - C91.Z2 - C C C C C C Malignant neoplasm of prostate Follicular lymphoma grade I, unspecified site - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-cell proliferations Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] Acute lymphoblastic leukemia not having achieved remission - Acute lymphoblastic leukemia, in relapse Prolymphocytic leukemia of B-cell type not having achieved remission - Prolymphocytic leukemia of T-cell type, in relapse Lymphoid leukemia, unspecified not having achieved remission - Lymphoid leukemia, unspecified, in relapse Mature B-cell leukemia Burkitt-type not having achieved remission - Other lymphoid leukemia, in relapse Acute myeloblastic leukemia, not having achieved remission - Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission Chronic myeloid leukemia, BCR/ABL-positive, in relapse - Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse - Myeloid sarcoma, not having achieved remission

15 C C Myeloid sarcoma, in relapse - Acute myeloid leukemia with 11q23- abnormality in relapse C92.90 Myeloid leukemia, unspecified, not having achieved remission C92.92 Myeloid leukemia, unspecified in relapse C92.A0 - C92.Z0 - Acute myeloid leukemia with multilineage dysplasia, not having achieved remission - Other myeloid leukemia not having achieved remission C92.Z2 Other myeloid leukemia, in relapse C93.00 Acute monoblastic/monocytic leukemia, not having achieved remission C C Acute monoblastic/monocytic leukemia, in relapse - Chronic myelomonocytic leukemia not having achieved remission C C Chronic myelomonocytic leukemia, in relapse - Juvenile myelomonocytic leukemia, not having achieved remission C93.32 Juvenile myelomonocytic leukemia, in relapse C93.90 Monocytic leukemia, unspecified, not having achieved remission C93.92 Monocytic leukemia, unspecified in relapse C93.Z0 Other monocytic leukemia, not having achieved remission C93.Z2 Other monocytic leukemia, in relapse C94.00 Acute erythroid leukemia, not having achieved remission C94.02 Acute erythroid leukemia, in relapse C C Opens Multifocal and multisystemic (disseminated) Langerhans-cell in a new histiocytosis - Sarcoma of dendritic cells (accessory cells) C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified C96.A - C96.Z - G35 Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue Multiple sclerosis Showing 1 to 34 of 34 entries in Group 10 Group 11 Paragraph: Oxaliplatin for Injection (Eloxatin ) (J9263) Group 11 Codes: Show entries for Group 11 s that are Covered: Group 11Codes C C Opens Malignant neoplasm of upper third of esophagus - Malignant neoplasm of in a new stomach, unspecified

16 C17.1 Malignant neoplasm of jejunum C C Opens Malignant neoplasm of cecum - Malignant neoplasm of overlapping sites in a new of rectum, anus and anal canal C22.1 Intrahepatic bile duct carcinoma C23 - C Opens Malignant neoplasm of gallbladder - Malignant neoplasm of pancreas, in a new unspecified C26.9 Malignant neoplasm of ill-defined sites within the digestive system C45.9 Mesothelioma, unspecified C C Opens Malignant neoplasm of right ovary - Malignant neoplasm of uterine in a new adnexa, unspecified C C Malignant neoplasm of unspecified undescended testis - Malignant neoplasm of left testis, unspecified whether descended or undescended C80.1 Malignant (primary) neoplasm, unspecified C C C C C C C C C C C C C C C C C C C C Follicular lymphoma grade I, lymph nodes of head, face, and neck - Follicular lymphoma grade I, lymph nodes of multiple sites Follicular lymphoma grade II, lymph nodes of head, face, and neck - Follicular lymphoma grade II, lymph nodes of multiple sites Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck - Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck - Follicular lymphoma grade IIIa, lymph nodes of multiple sites Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck - Follicular lymphoma grade IIIb, lymph nodes of multiple sites Diffuse follicle center lymphoma, unspecified site - Diffuse follicle center lymphoma, extranodal and solid organ sites Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck - Cutaneous follicle center lymphoma, lymph nodes of multiple sites Other types of follicular lymphoma, lymph nodes of head, face, and neck - Other types of follicular lymphoma, lymph nodes of multiple sites Follicular lymphoma, unspecified, lymph nodes of head, face, and neck - Follicular lymphoma, unspecified, lymph nodes of multiple sites Small cell B-cell lymphoma, unspecified site - Mantle cell lymphoma, extranodal and solid organ sites

17 C C C C C C C C C84.A0 - C84.Z9 - C C C88.4 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck - Diffuse large B-cell lymphoma, extranodal and solid organ sites Other non-follicular lymphoma, unspecified site - Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites Anaplastic large cell lymphoma, ALK-positive, unspecified site - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-cell proliferations Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] Showing 1 to 27 of 27 entries in Group 11 Group 12 Paragraph: Paclitaxel Protein-Bound Particles, 1 mg (Abraxane ) (J9264) Group 12 Codes: Show entries for Group 12 s that are Covered: Group 12Codes C C Opens in Malignant neoplasm of head of pancreas - Malignant neoplasm of a new pancreatic duct C C Opens in Malignant neoplasm of other parts of pancreas - Malignant neoplasm a new of pancreas, unspecified C33 - C Opens in Malignant neoplasm of trachea - Malignant neoplasm of unspecified a new part of left bronchus or lung C43.9 Malignant melanoma of skin, unspecified C45.1 Mesothelioma of peritoneum C C Opens in Malignant neoplasm of specified parts of peritoneum - Malignant a new neoplasm of overlapping sites of retroperitoneum and peritoneum C C Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast

18 C C Opens in Malignant neoplasm of right ovary - Malignant neoplasm of uterine a new adnexa, unspecified D03.9 Melanoma in situ, unspecified Z85.43 Personal history of malignant neoplasm of ovary Showing 1 to 10 of 10 entries in Group 12 Group 13 Paragraph: Pemetrexed (Alimta ) (J9305) Group 13 Codes: Show entries for Group 13 s that are Covered: Group 13Codes C33 - C Opens in a Malignant neoplasm of trachea - Malignant neoplasm of new unspecified part of left bronchus or lung C38.4 Malignant neoplasm of pleura C C Opens in a Mesothelioma of pleura - Mesothelioma of peritoneum new C48.1 Malignant neoplasm of specified parts of peritoneum C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum C C Opens in a Malignant neoplasm of right ovary - Malignant neoplasm of uterine new adnexa, unspecified C C Opens in a Malignant neoplasm of right renal pelvis - Malignant neoplasm of new bladder, unspecified Z85.43 Personal history of malignant neoplasm of ovary Showing 1 to 8 of 8 entries in Group 13 Group 14 Paragraph: Rituximab (Rituxan ) (J9310) Group 14 Codes: Show entries for Group 14 s that are Covered: Group 14Codes C C Follicular lymphoma grade I, unspecified site - Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites C C Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites

19 C84.A0 - C84.Z9 - Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell lymphomas, extranodal and solid organ sites C C Opens Unspecified B-cell lymphoma, unspecified site - Waldenstrom in a new macroglobulinemia Extranodal marginal zone B-cell lymphoma of mucosa-associated C88.4 lymphoid tissue [MALT-lymphoma] C C Acute lymphoblastic leukemia not having achieved remission - Acute lymphoblastic leukemia, in remission C C Chronic lymphocytic leukemia of B-cell type not having achieved remission - Chronic lymphocytic leukemia of B-cell type in relapse C91.40 Hairy cell leukemia not having achieved remission C91.42 Hairy cell leukemia, in relapse C C Opens Multifocal and multisystemic (disseminated) Langerhans-cell in a new histiocytosis - Sarcoma of dendritic cells (accessory cells) Malignant neoplasm of lymphoid, hematopoietic and related tissue, C96.9 unspecified C96.A - C96.Z - Opens Histiocytic sarcoma - Other specified malignant neoplasms of in a new lymphoid, hematopoietic and related tissue D47.3 Essential (hemorrhagic) thrombocythemia D D Opens Drug-induced autoimmune hemolytic anemia - Other autoimmune in a new hemolytic anemias D D Opens Immune thrombocytopenic purpura - Congenital and hereditary in a new thrombocytopenia purpura E88.01 Alpha-1-antitrypsin deficiency L L Opens Pemphigus vulgaris - Pemphigus, unspecified in a new L L Opens Bullous pemphigoid - Cicatricial pemphigoid in a new L L Opens Other pemphigoid - Pemphigoid, unspecified in a new M M Felty's syndrome, unspecified site - Felty's syndrome, multiple sites M M Rheumatoid vasculitis with rheumatoid arthritis of unspecified site - Adult-onset Still's disease M M Other specified rheumatoid arthritis, unspecified site - Rheumatoid arthritis, unspecified M M Unspecified juvenile rheumatoid arthritis of unspecified site - Unspecified juvenile rheumatoid arthritis, multiple sites M M Juvenile rheumatoid arthritis with systemic onset, unspecified site - Juvenile arthritis, unspecified, multiple sites M M Opens Polyarteritis nodosa - Juvenile polyarteritis in a new M30.8 Other conditions related to polyarteritis nodosa M31.1 Thrombotic microangiopathy

20 M M Wegener's granulomatosis without renal involvement - Wegener's granulomatosis with renal involvement M31.7 Microscopic polyangiitis R76.0 Raised antibody titer R R Opens Other specified abnormal immunological findings in serum - Abnormal in a new immunological finding in serum, unspecified Showing 1 to 31 of 31 entries in Group 14 Group 15 Paragraph: Topotecan Hydrochloride (Hycamtin ) (J9351) Group 15 Codes: Show entries for Group 15 s that are Covered: Group 15Codes C33 - C Opens Malignant neoplasm of trachea - Malignant neoplasm of unspecified part in a new of left bronchus or lung C45.1 Mesothelioma of peritoneum C48.1 Malignant neoplasm of specified parts of peritoneum C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum C C Opens Malignant neoplasm of endocervix - Malignant neoplasm of cervix uteri, in a new unspecified C C Opens Malignant neoplasm of endometrium - Malignant neoplasm of fundus in a new uteri C54.9 Malignant neoplasm of corpus uteri, unspecified C C Opens Malignant neoplasm of right ovary - Malignant neoplasm of uterine in a new adnexa, unspecified C88.8 Other malignant immunoproliferative diseases C C Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission - Chronic myeloid leukemia, BCR/ABL-positive, in relapse C C D D Acute panmyelosis with myelofibrosis not having achieved remission - Myelodysplastic disease, not classified Refractory anemia without ring sideroblasts, so stated - Refractory anemia with excess of blasts 2 D46.4 Refractory anemia, unspecified D46.9 Myelodysplastic syndrome, unspecified

21 D46.A - D46.C - D46.Z Refractory cytopenia with multilineage dysplasia - Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality Other myelodysplastic syndromes D47.1 Chronic myeloproliferative disease D47.3 Essential (hemorrhagic) thrombocythemia D47.9 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue Z85.43 Personal history of malignant neoplasm of ovary Showing 1 to 21 of 21 entries in Group 15 Group 16 Paragraph: Trastuzumab (Herceptin ) (J9355) Group 16 Codes: Show entries for Group 16 s that are Covered: Group 16Codes C C Opens in Malignant neoplasm of upper third of esophagus - Malignant a new neoplasm of stomach, unspecified C C Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast C79.2 Secondary malignant neoplasm of skin C79.81 Secondary malignant neoplasm of breast D D Opens in Neoplasm of uncertain behavior of stomach - Neoplasm of uncertain a new behavior of rectum D37.8 Neoplasm of uncertain behavior of other specified digestive organs D37.9 Neoplasm of uncertain behavior of digestive organ, unspecified Showing 1 to 7 of 7 entries in Group 16 s that are Not Covered Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new

22 Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revisio Revision n History History Revision History Explanation Date Numbe r 10/01/201 R5 5 10/01/201 R4 5 Group paragraph and ICD-10 diagnosis codes for J9265 was invalid after December 31, 2014 and was removed from this Article. The Cahaba GBA Part B automated payment edit for the chemotherapeutic agents listed below have been revised. The following ICD-10 codes have been added: Cetuximab (Erbitux ) (J9055) C /01/201 R3 5 10/01/201 R2 5 10/01/201 R1 5 Topotecan Hydrochloride (Hycamtin ) J9351 C54.1 C54.3, C54.9 The Cahaba GBA Part B automated payment edit for the chemotherapeutic agent Carboplatin (Paraplatin )(J9045)has been revised. The following ICD- 10 codes has been added: C7A.1 Malignant poorly differentiated neuroendocrine tumors C7A.8 Other malignant neuroendocrine tumors Code Updates: 2015 CPT/HCPCS Code Annual Update was applied. The following CPT/HCPCS codes were deleted: J9265 was deleted from Group 1 The Cahaba GBA Part B automated payment edits for the chemotherapeutic agents listed below have been revised. The following ICD-10 codes have been added: J9035- Bevacizumab(Avastin ):C17.8,C47.0,C49.0,C54.1,C54.2,C54.3,C54.9,C53.0 J Bortezomib (Velcade ): C84.40,C84.49 J Carboplatin (Paraplatin ):C4A.60,C4A.61,C4A.62,C38.4,C21.2,C21.8 J Cetuximab (Erbitux ):C44.300, C44.301, C44.309, C44.310, C44.311, C44.319, C44.320, CC44.321, C44.329, C44.390, C44.391, C J Irinotecan Hydrochloride (Camptosar ): C17.8 J Oxaliplatin for Injection (Eloxatin ): C26.9,C45.9,C80.1 J Paclitaxel Protein-Bound Particles: C43.9,D03.6 J Paclitaxel 30 mg: C21.2,C21.8

23 Associated Documents Related Local Coverage Document(s) N/A Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 02/17/2015 with effective dates 10/01/ N/A Updated on 02/16/2015 with effective dates 10/01/ N/A Updated on 02/16/2015 with effective dates 10/01/ N/A Updated on 02/12/2015 with effective dates 10/01/ N/A Updated on 10/02/2014 with effective dates 10/01/ N/A Updated on 04/14/2014 with effective dates 10/01/ N/A Keywords Chemotherapy Read the Article Disclaimer opens in new