Synagis (Palivizumab)

Transcription

1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable te: Click the hyperlink to navigate directly to that section. Revision tes Updated criteria logic and criteria logic diagram for the season Added supporting tables for steps 3, 4, 8, 17, 19, and 20 September 8, 2014 Copyright Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN SYNAGIS 50 MG/0.5 ML VIAL SYNAGIS 100 MG/1 ML VIAL September 8, 2014 Copyright Health Information Designs, LLC 2

3 Clinical Edit Criteria Logic For Initial Requests: 1. Is the client s chronological age less than (<) 12 months at the beginning of the RSV season for the client s county of residence? [ ] (Go to #2) [ ] (Go to #15) 2. Is the client s chronological age less than (<) 6 months at the beginning of the RSV season for the client s county of residence? [ ] (Go to #3) [ ] (Go to #4) 3. Is the client s gestational age less than (<) 31 6/7 weeks? [ ] (Go to #24) [ ] (Go to #7) 4. Is the client s gestational age less than or equal to ( ) 28 6/7 weeks? [ ] (Go to #24) [ ] (Go to #5) 5. Does the client have a diagnosis of chronic lung disease (CLD) of prematurity? [ ] (Go to #6) [ ] (Go to #7) 6. Is the client s gestational age less than or equal to ( ) 31 6/7 weeks? [ ] (Go to #24) [ ] (Go to #7) 7. Does the client have a severe congenital abnormality of the airway? [ ] (Go to #24) [ ] (Go to #8) 8. Does the client have a diagnosis of severe neuromuscular disease that compromises the handling of respiratory tract secretions? [ ] (Go to #24) [ ] (Go to #9) September 8, 2014 Copyright Health Information Designs, LLC 3

4 9. Does the client have a diagnosis of hemodynamically significant heart disease? [ ] (Go to #10) [ ] (Go to #21) 10. Does the client have a diagnosis of heart failure? [ ] (Go to #11) [ ] (Go to #12) 11. Does the client have 1 claim for a medication for heart failure in the last 60 days? [ ] (Go to #24) [ ] (Go to #12) 12. Does the client have a diagnosis of moderate to severe pulmonary hypertension? [ ] (Go to #24) [ ] (Go to #13) 13. Does the client have a diagnosis of cyanotic heart disease? [ ] (Go to #14) [ ] (Go to #15) 14. Is prescribing provider a pediatric cardiologist, or has the prescribing provider indicated the name of consulting pediatric cardiologist and date of consultation? [ ] (Go to #24) [ ] (Deny) 15. Is the client less than (<) 24 months chronological age and greater than or equal to ( ) 12 months chronological age at the beginning of the RSV season for the client s county of residence? [ ] (Go to #16) [ ] (Go to #21) 16. Does the client have a diagnosis of chronic lung disease (CLD) of prematurity? [ ] (Go to #17) [ ] (Go to #19) 17. Is the client s gestational age less than or equal to ( ) 31 6/7 weeks? [ ] (Go to #18) [ ] (Go to #19) 18. Does the client have a history of any of the following in the last 180 days: chronic use of corticosteroids, diuretics, long-term mechanical ventilator, bronchodilator therapy, and/or supplemental oxygen? [ ] (Go to #24) [ ] (Go to #19) September 8, 2014 Copyright Health Information Designs, LLC 4

5 19. Does the client have a diagnosis of an identified disease state that will leave them profoundly immunocompromised during the RSV season? [ ] (Go to #24) [ ] (Go to #20) 20. Has the client had a cardiac transplant during the RSV season? [ ] (Go to #24) [ ] (Go to #21) 21. Is the client less than (<) 24 months chronological age at the beginning of the RSV season for the client s county of residence? [ ] (Go to #22) [ ] (Deny) 22. Does the client have a condition other than those specified in Section 3 of the Synagis form? [manual step] [ ] (Go to #23) [ ] (Deny) 23. Has the prescribing provider indicated the name of the subspecialist and date of consultation OR is the requesting provider a subspecialist? [ ] (Go to #24) [ ] (Deny) 24. Is the claim for 1 pack of either the 50mg or 100mg vials? [ ] (Go to #25) [ ] (Deny) 25. Are there greater than (>) 4 dates of service for palivizumab since the beginning of the current RSV season (determined by client s county of residence) until today? [ ] (Deny) [ ] (Approve request for 1 dose) September 8, 2014 Copyright Health Information Designs, LLC 5

6 For Renewal Requests: 1. Has the client been hospitalized for RSV since the last palivizumab dose? [ ] (Deny) [ ] (Go to #2) 2. Has the pharmacy indicated the client s weight? [ ] (Go to #3) [ ] (Deny) 3. Did the pharmacy indicate date of last palivizumab dose? [ ] (Go to #4) [ ] (Deny) 4. Are there greater than (>) 4 dates of service for palivizumab since the beginning of the current RSV season (determined by client s county of residence) until today? [ ] (Deny) [ ] (Approve request for 1 dose) September 8, 2014 Copyright Health Information Designs, LLC 6

7 Clinical Edit Criteria Logic Diagram For Initial Requests: Step 1 Is the client s chronological age < 12 months at the beginning of the RSV season for the client s county of residence? Step 2 Is the client s chronological age < 6 months at the beginning of the RSV season for the client s county of residence? Step 3 Is the client s gestational age < 31 6/7 weeks? Go to Step 24 Go to Step 7 Step 4 Step 5 Step 6 Go to Step 15 Is the client s Does the client have a Is the client s gestational age 28 6/7 diagnosis of chronic gestational age Go to Step 24 weeks? lung disease (CLD) of 31 6/7 weeks? prematurity? Step 7 Go to Step 24 Go to Step 21 Does the client have a severe congenital abnormality of the airway? Go to Step 24 Step 8 Step 11 Does the client have 1 claim for a medication for heart failure in the last 60 days? Step 10 Does the client have a diagnosis of heart failure? Step 9 Does the client have a diagnosis of hemodynamically significant heart disease? Does the client have a diagnosis of severe neuromuscular disease that compromises the handling of respiratory tract secretions? Step 14 Go to Step 24 Go to Step 24 Step 12 Does the client have a diagnosis of moderate to severe pulmonary hypertension? Step 13 Does the client have a diagnosis of cyanotic heart disease? Is the prescribing provider a pediatric cardiologist, or has the prescribing provider indicated the name of consulting pediatric cardiologist and date of consultation? Go to Step 24 Go to Step 24 Go to Step 15 Deny Request September 8, 2014 Copyright Health Information Designs, LLC 7

8 Step 15 Step 18 Is the client < 24 months chronological age and 12 months chronological age at the beginning of the RSV season for the client s county of residence? Step 16 Does the client have a diagnosis of chronic lung disease (CLD) of prematurity? Step 17 Is the client s gestational age 31 6/7 weeks? Does the client have any of the following in the last 180 days: chronic use of corticosteroids, diuretics, long-term mechanical ventilator, bronchodilator therapy and/or supplemental oxygen? Go to Step 24 Step 19 Go to Step 21 Does the client have a diagnosis of an identified disease state that will leave them profoundly immunocompromised during the RSV season? Step 20 Has the client had a cardiac transplant during the RSV season? Go to Step 21 Go to Step 24 Go to Step 24 September 8, 2014 Copyright Health Information Designs, LLC 8

9 Step 21 Is the client < 24 months chronological age at the beginning of the RSV season for the client s county of residence? Step 22 Does the client have a condition other than those listed in Section 3 on the Synagis form? [manual] Step 23 Is the prescribing provider a pediatric subspecialist, or has the prescribing provider indicated the name of consulting pediatric subspecialist and date of consultation? Step 24 Is the claim for 1 pack of either the 50mg or 100mg vials? Deny Request Step 25 Deny Request Deny Request Deny Request Are there > 4 dates of service for palivizumab since the beginning of the current RSV season until today? Approve Request (1 dose) Deny Request September 8, 2014 Copyright Health Information Designs, LLC 9

10 For Renewal Requests: Step 1 Has the client been hospitalized for RSV since the last palivizumab dose? Step 2 Has the pharmacy indicated the client s weight? Step 3 Did the pharmacy indicate date of last palivizumab dose? Step 4 Are there > 4 dates of service for palivizumab since the beginning of the current RSV season (determined by client s county of residence) until today? Approve Request (1 dose) Deny Request Deny Request Deny Request Deny Request September 8, 2014 Copyright Health Information Designs, LLC 10

11 Clinical Edit Criteria Supporting Tables ICD-9 Code Step 3 (gestational age less than 31 6/7 weeks) Look back timeframe: N/A Description LESS THAN 24 COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS Step 4 (gestational age less than or equal to 28 6/7 weeks) Look back timeframe: N/A ICD-9 Code Description LESS THAN 24 COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS Step 5 (diagnosis of CLD of prematurity) CLD of Prematurity Diagnosis Codes ICD-9 Code Description 4940 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION 4941 BRONCHIECTASIS WITH ACUTE EXACERBATION CHRONIC RESPIRATORY FAILURE 7484 CONGENITAL CYSTIC LUNG 7485 AGENESIS, HYPOPLASIA, AND DYSPLASIA OF LUNG CONGENITAL BRONCHIECTASIS September 8, 2014 Copyright Health Information Designs, LLC 11

12 Step 5 (diagnosis of CLD of prematurity) CLD of Prematurity Diagnosis Codes 7506 CONGENITAL HIATUS HERNIA 7566 ANOMALIES OF DIAPHRAGM 7700 CONGENITAL PNEUMONIA 7701 FETAL AND NEWBORN ASPIRATION UNSPECIFIED MECONIUM ASPIRATION WITHOUT RESPIRATORY SYMPTOMS MECONIUM ASPIRATION WITH RESPIRATORY SYMPTOMS ASPIRATION OF CLEAR AMNIOTIC FLUID WITHOUT RESPIRATORY SYMPTOMS ASPIRATION OF CLEAR AMNIOTIC FLUID WITH RESPIRATORY SYMPTOMS ASPIRATION OF BLOOD WITHOUT RESPIRATORY SYMPTOMS ASPIRATION OF BLOOD WITH RESPIRATORY SYMPTOMS OTHER FETAL AND NEWBORN ASPIRATION WITHOUT RESPIRATORY SYMPTOMS OTHER FETAL AND NEWBORN ASPIRATION WITH RESPIRATORY SYMPTOMS 7702 INTERSTITIAL EMPHYSEMA AND RELATED CONDITIONS 7703 PULMONARY HEMORRHAGE 7704 PRIMARY ATELECTASIS 7705 OTHER AND UNSPECIFIED ATELECTASIS 7707 CHRONIC RESPIRATORY DISEASE ARISING IN THE PERINATAL PERIOD Step 6 (gestational age less than or equal to 31 6/7 weeks) Look back timeframe: N/A Gestational Age 31 6/7 Weeks Diagnosis Codes ICD-9 Code Description LESS THAN 24 COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS COMPLETED WEEKS September 8, 2014 Copyright Health Information Designs, LLC 12

13 Step 7 (diagnosis of severe congenital abnormality of the airway) Look back timeframe: N/A ICD-9 Code Description CONGENITAL CENTRAL ALVEOLAR HYPOVENTILATION 5191 OTHER DISEASES OF TRACHEA AND BRONCHUS NOT ELSEWHERE CLASSIFIED 748 CONGENITAL ANOMALIES OF RESPIRATORY SYSTEM 7480 CHOANAL ATRESIA 7481 OTHER ANOMALIES OF NOSE 7482 WEB OF LARYNX 7483 OTHER ANOMALIES OF LARYNX, TRACHEA, AND BRONCHUS 7484 CONGENITAL CYSTIC LUNG 7485 AGENESIS, HYPOPLASIA, AND DYSPLASIA OF LUNG ANOMALY OF LUNG, UNSPECIFIED CONGENITAL BRONCHIECTASIS OTHER CONGENITAL ANOMALIES OF LUNG 7488 OTHER SPECIFIED ANOMALIES OF RESPIRATORY SYSTEM 7489 UNSPECIFIED ANOMALY OF RESPIRATORY SYSTEM MACROGLOSSIA 7509 UNSPECIFIED ANOMALY OF UPPER ALIMENTARY TRACT 7566 ANOMALIES OF DIAPHRAGM OTHER SPECIFIED CONGENITAL ANOMALIES ICD-9 Code Step 8 (diagnosis of severe neuromuscular disease) Look back timeframe: N/A Description 0450 ACUTE PARALYTIC POLIOMYELITIS SPECIFIED AS BULBAR ACUTE PARALYTIC POLIOMYELITIS SPECIFIED AS BULBAR, POLIOVIRUS, UNSPECIFIED TYPE ACUTE PARALYTIC POLIOMYELITIS SPECIFIED AS BULBAR, POLIOVIRUS TYPE I ACUTE PARALYTIC POLIOMYELITIS SPECIFIED AS BULBAR, POLIOVIRUS TYPE II September 8, 2014 Copyright Health Information Designs, LLC 13

14 ICD-9 Code Step 8 (diagnosis of severe neuromuscular disease) Description Look back timeframe: N/A ACUTE PARALYTIC POLIOMYELITIS SPECIFIED AS BULBAR, POLIOVIRUS TYPE III 0451 ACUTE POLIOMYELITIS WITH OTHER PARALYSIS ACUTE POLIOMYELITIS WITH OTHER PARALYSIS, POLIOVIRUS, UNSPECIFIED TYPE ACUTE POLIOMYELITIS WITH OTHER PARALYSIS, POLIOVIRUS TYPE I ACUTE POLIOMYELITIS WITH OTHER PARALYSIS, POLIOVIRUS TYPE II ACUTE POLIOMYELITIS WITH OTHER PARALYSIS, POLIOVIRUS TYPE III 3300 LEUKODYSTROPHY 3301 CEREBRAL LIPIDOSES 3332 MYOCLONUS 3340 FRIEDREICH S ATAXIA 3341 HEREDITARY SPASTIC PARAPLEGIA 3350 WERDNIG-HOFFMANN DISEASE SPINAL MUSCULAR ATROPHY, UNSPECIFIED KUGELBERG-WELANDER DISEASE AMYOTROPHIC LATERAL SCLEROSIS PROGRESSIVE MUSCULAR ATROPHY PROGRESSIVE BULBAR PALSY PSEUDOBULBAR PALSY PRIMARY LATERAL SCLEROSIS Step 9 (diagnosis of hemodynamically significant heart disease) ICD-9 Code Description 3960 MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS 3961 MITRAL VALVE STENOSIS AND AORTIC VALVE INSUFFICIENCY 3962 MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE STENOSIS 3963 MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE INSUFFICIENCY 3968 MULTIPLE INVOLVE OF MITRAL AND AORTIC VALVES 3969 MITRAL AND AORTIC VALVE DISEASES, UNSPECIFIED September 8, 2014 Copyright Health Information Designs, LLC 14

15 Step 9 (diagnosis of hemodynamically significant heart disease) ICD-9 Code Description 4150 ACUTE COR PULMONALE 4160 PRIMARY PULMONARY HYPERTENSION 4168 OTHER CHRONIC PULMONARY HEART DISEASES 4170 ARTERIOVENOUS FISTULA OF PULMONARY VESSELS 4171 ANEURYSM OF PULMONARY ARTERY 4178 OTHER SPECIFIED DISEASES OF PULMONARY CIRCULATION 4179 UNSPECIFIED DISEASE OF PULMONARY CIRCULATION 4229 ACUTE MYOCARDITIS, UNSPECIFIED IDIOPATHIC MYOCARDITIS SEPTIC MYOCARDITIS TOXIC MYOCARDITIS OTHER ACUTE MYOCARDITIS 4240 MITRAL VALVE DISORDERS 4241 AORTIC VALVE DISORDERS 4242 TRICUSPID VALVE DISORDERS, SPECIFIED AS NONRHEUMATIC 4243 PULMONARY VALVE DISORDERS 4249 ENDOCARDITIS VALVE UNSPECIFIED ENDOCARDITIS VALVE UNSPECIFIED, UNSPECIFIED CAUSE ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE OTHER ENDOCARDITIS, VALVE UNSPECIFIED 425 CARDIOMYOPATHY 4251 HYPERTROPHIC CARDIOMYOPATHY HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY OTHER HYPERTROPHIC CARDIOMYOPATHY 4252 OBSCURE CARDIOMYOPATHY OF AFRICA 4253 ENDOCARDIAL FIBROELASTOSIS 4254 OTHER PRIMARY CARDIOMYOPATHIES 4255 ALCOHOLIC CARDIOMYOPATHY 4257 NUTRITIONAL AND METABOLIC CARDIOPATHY 4258 IN OTHER DISEASES CLASSIFIED ELSEWHERE 4259 SECONDARY CARDIOMYOPATHY, UNSPECIFIED 4272 SYSTOLIC HEART FAILURE September 8, 2014 Copyright Health Information Designs, LLC 15

16 Step 9 (diagnosis of hemodynamically significant heart disease) ICD-9 Code Description 428 HEART FAILURE 4281 LEFT HEART FAILURE UNSPECIFIED ACUTE SYSTOLIC HEART FAILURE CHRONIC SYSTOLIC HEART FAILURE ACUTE ON CHRONIC SYSTOLIC HEART FAILURE 4283 DIASTOLIC HEART FAILURE ACUTE DIASTOLIC HEART FAILURE CHRONIC DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE 4284 COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE UNSPECIFIED ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE UNSPECIFIED ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 4290 MYOCARDITIS, UNSPECIFIED 4291 MYOCARDITIS, DEGENERATION 4292 CARDIOVASCULAR DISEASE, UNSPECIFIED 4293 CARDIOMEGALY 4294 FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY 4295 RUPTURE OF CHORDAE TENDINEAE 4296 RUPTURE OF PAPILLARY MUSCLE 7450 COMMON TRUNCUS 7451 TRANSPOSITION OF GREAT VESSELS COMPLETE TRANSPOSITION OF GREAT VESSELS DOUBLE OUTLET RIGHT VENTRICLE CORRECTED TRANSPOSITION OF GREAT VESSELS OTHER TRANSPOSITION OF GREAT VESSELS 7452 TETRALOGY OF FALLOT 7453 COMMON VENTRICLE September 8, 2014 Copyright Health Information Designs, LLC 16

17 Step 9 (diagnosis of hemodynamically significant heart disease) ICD-9 Code Description 7454 VENTRICLE SEPTAL DEFECT 7455 OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFECT 7456 ENDOCARDIAL CUSHION DEFECTS ENDOCARDIAL CUSION DEFECT, UNSPECIFIED TYPE OSTIUM PRIMUM DEFECT OTHER ENDOCARDIAL CUSHION DEFECTS 7457 COR BILOCULARE 7458 OTHER BULBUS CORDIS ANOMALIES AND ANOMALIES OF CARDIAC SEPTAL CLOSURE 7459 UNSPECIFIED DEFECT OF SEPTAL CLOSURE 7460 ANOMALIES OF PULMONARY VALVE CONGENITAL ANOMALIES OF PULMONARY VALVE ATRESIA OF PULMONARY VALVE, CONGENITAL STENOSIS OF PULMONARY VALVE, CONGENITAL OTHER CONGENITAL ANOMALIES OF PULMONARY VALVE 7461 TRICUSPID ATRESIA AND STENOSIS, CONGENITAL 7462 EBSTEIN S ANOMALY 7463 CONGENITAL STENOSIS OF AORTIC VALVE 7464 CONGENITAL INSUFFICIENCY OF AORTIC VALVE 7465 CONGENITAL MITRAL STENOSIS 7466 CONGENITAL MITRAL INSUFFICIENCY 7467 HYPOPLASTIC LEFT HEART SYNDROME 7468 OTHER SPECIFIED CONGENITAL ANORMALIES OF HEART SUBAORTIC STENOSIS COR TRIATRIATUM INFUNDIBULAR PULMONIC STENOSIS OBSTRUCTIVE ANOMALIES OF HEART, NOT ELSEWHERE CLASSIFIED CORONARY ARTERY ANOMALY CONGENITAL HEART BLOCK MALPOSITION OF HEAR AND CARDIAC APEX OTHER SPECIFIED CONGENITAL ANOMALIES OF HEART 7469 UNSPECIFED CONGENITAL ANOMALY OF HEART September 8, 2014 Copyright Health Information Designs, LLC 17

18 Step 9 (diagnosis of hemodynamically significant heart disease) ICD-9 Code Description 7470 PATENT DUCTUS ARTERIOUS (PREDUCTAL) (POSTDUCTAL) INTERRUPTION OF AORTIC ARCH 7472 OTHER CONGENITAL ANOMALIES OF AORTA ANOMALY OF AORTA, UNSPECIFIED ANOMALIES OF AORTIC ARCH ATRESIA AND STENOSIS OF AORTA OTHER ANOMALIES OF AORTA 7473 CONGENITAL ANOMALIES OF PULMONARY ARTERY PULMONARY ARTERY COARCTATION AND ATRESIA PULMONARY ARTERIOVENOUS MALFORMATION OTHER ANOMALIES OF PULMONARY ARTERY AND PULMONARY CIRCULATION ANOMALY OF GREAT VEINS, UNSPECIFIED TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION OTHER ANOMALIES OF GREAT VEINS PERSISTENT FETAL CIRCULATION Step 16 (diagnosis of CLD of prematurity) For the list of diagnosis codes that pertain to this step, see the CLD of Prematurity Diagnosis Codes table. Step 17 (gestational age less than or equal to 31 6/7 weeks) Look back timeframe: N/A For the list of diagnosis codes that pertain to this step, see the Gestational Age 31 6/7 Weeks Diagnosis Codes table. September 8, 2014 Copyright Health Information Designs, LLC 18

19 ICD-9 Code Step 19 (diagnosis of profoundly immunocompromised) Description V42.0 KIDNEY REPLACED BY TRANSPLANT V42.6 LUNG REPLACED BY TRANSPLANT V42.7 LIVER REPLACED BY TRANSPLANT V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT CPT Code Description RADIATION THERAPY PLANNING RADIATION THERAPY PLANNING RADIATION THERAPY PLANNING SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD RADIATION THERAPY PLANNING RADIATION THERAPY DOSE PLAN RADIOTHERAPY DOS PLAN, IMRT RADIATION THERAPY DOSE PLAN RADIATION THERAPY DOSE PLAN RADIATION THERAPY DOSE PLAN RADIATION THERAPY PORT PLAN RADIATION THERAPY DOSE PLAN RADIATION THERAPY DOSE PLAN RADIATION THERAPY DOSE PLAN SPECIAL RADIATION DOSIMETRY RADIATION TREATMENT AID(S) RADIATION TREATMENT AID(S) RADIATION TREATMENT AID(S) RADIATION PHYSICS CONSULT DESIGN MLC DEVICE FOR IMRT RADIATION PHYSICS CONSULT SRS, MULTISOURCE SRS, LINEAR BASED September 8, 2014 Copyright Health Information Designs, LLC 19

20 Step 19 (diagnosis of profoundly immunocompromised) SBRT DELIVERY EXTERNAL RADIATION DOSIMETRY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIATION TREATMENT DELIVERY RADIOLOGY PORT FILM(S) RADIATION TX DELIVERY, IMRT STEREOSCOPIC X-RAY GUIDANCE NEUTRON BEAM TX, SIMPLE NEUTRON BEAM TX, COMPLEX RADIATION TX MANAGEMENT, X RADIATION THERAPY MANAGEMENT STEREOTACTIC RADIATION TRMT SBRT MANAGEMENT SPECIAL RADIATION TREATMENT RADIATION THERAPY MANAGEMENT PROTON TRMT, SIMPLE W/O COMP PROTON TRMT, SIMPLE W/COMP PROTON TRMT, INTERMEDIATE PROTON TREATMENT, COMPLEX CHEMO, ANTI-NEOPL, SQ/IM CHEMO HORMON ANTINEOPL SQ/IM CHEMO INTRALESIONAL, UP TO 7 September 8, 2014 Copyright Health Information Designs, LLC 20

21 Step 19 (diagnosis of profoundly immunocompromised) CHEMO INTRALESIONAL OVER CHEMO, IV PUSH, SNGL DRUG CHEMO, IV PUSH, ADDL DRUG CHEMO, IV INFUSION, 1 HR CHEMO, IV INFUSION, ADDL HR CHEMO PROLONG INFUSE W/PUMP CHEMO IV INFUS EACH ADDL SEQ CHEMO, IA, PUSH TECNIQUE CHEMO IA INFUSION UP TO 1 HR CHEMO IA INFUSE EACH ADDL HR CHEMOTHERAPY INFUSION METHOD CHEMOTHERAPY, INTRACAVITARY CHEMOTHERAPY, INTRACAVITARY CHEMOTHERAPY, INTO CNS REFILL/MAINT, PORTABLE PUMP CHEMOTHERAPY INJECTION CHEMOTHERAPY, UNSPECIFIED J9000 J9001 J9010 J9015 J9020 J9027 J9033 J9040 J9041 J9045 J9050 J9055 J9060 J9062 J9065 J9070 DOXORUBICIN HCL INJECTION DOXORUBICIN HCL LIPOSOME INJ ALEMTUZUMAB INJECTION ALDESLEUKIN INJECTION ASPARAGINASE INJECTION CLOFARABINE INJECTION BENDAMUSTINE INJECTION BLEOMYCIN SULFATE INJECTION BORTEZOMIB INJECTION CARBOPLATIN INJECTION CARMUSTINE INJECTION CETUXIMAB INJECTION CISPLATIN 10 MG INJECTION CISPLATIN 50 MG INJECTION INJ CLADRIBINE PER 1 MG CYCLOPHOSPHAMIDE 100 MG INJ September 8, 2014 Copyright Health Information Designs, LLC 21

22 J9080 J9090 J9091 J9092 J9093 J9094 J9095 J9096 J9097 J9098 J9100 J9110 J9120 J9130 J9140 J9150 J9151 J9155 J9160 J9170 J9171 J9178 J9181 J9182 J9185 J9190 J9200 J9201 J9206 J9207 J9208 J9211 J9261 Step 19 (diagnosis of profoundly immunocompromised) CYCLOPHOSPHAMIDE 200 MG INJ CYCLOPHOSPHAMIDE 500 MG INJ CYCLOPHOSPHAMIDE 1.0 GRM INJ CYCLOPHOSPHAMIDE 2.0 GRM INJ CYCLOPHOSPHAMIDE LYOPHILIZED CYCLOPHOSPHAMIDE LYOPHILIZED CYCLOPHOSPHAMIDE LYOPHILIZED CYCLOPHOSPHAMIDE LYOPHILIZED CYCLOPHOSPHAMIDE LYOPHILIZED CYTARABINE LIPOSOME INJ CYTARABINE HCL 100 MG INJ CYTARABINE HCL 500 MG INJ DACTINOMYCIN INJECTION DACARBAZINE 10 MG INJ DACARBAZINE 200 MG INJ DAUNORUBICIN INJECTION DAUNORUBICIN CITRATE INJ DEGARELIX INJECTION DENILEUKIN DIFTITOX INJ DOCETAXEL INJECTION DOCETAXEL INJECTION INJ, EPIRUBICIN HCL, 2 MG ETOPOSIDE INJECTION ETOPOSIDE 100 MG INJ FLUDARABINE PHOSPHATE INJ FLUOROURACIL INJECTION FLOXURIDINE INJECTION GEMCITABINE HCL INJECTION IRINOTECAN INJECTION IXABEPILONE INJECTION IFOSFOMIDE INJECTION IDARUBICIN HCL INJECTION NELARABINE INJECTION September 8, 2014 Copyright Health Information Designs, LLC 22

23 J9263 J9264 J9265 J9266 J9268 J9280 J9290 J9291 J9303 J9305 J9320 J9328 J9330 J9340 J9350 J9355 J9357 J9360 J9370 J9375 J9380 J9390 J9600 J9999 Step 19 (diagnosis of profoundly immunocompromised) OXALIPLATIN PACLITAXEL PROTEIN BOUND PACLITAXEL INJECTION PEGASPARGASE INJECTION PENTOSTATIN INJECTION MITOMYCIN 5 MG INJ MITOMYCIN 20 MG INJ MITOMYCIN 40 MG INJ PANITUMUMAB INJECTION PEMETREXED INJECTION STREPTOZOCIN INJECTION TEMOZOLOMIDE INJECTION TEMSIROLIMUS INJECTION THIOTEPA INJECTION TOPOTECAN INJECTION TRASTUZUMAB INJECTION VALRUBICIN INJECTION VINBLASTINE SULFATE INJ VINCRISTINE SULFATE 1 MG INJ VINCRISTINE SULFATE 2 MG INJ VINCRISTINE SULFATE 5 MG INJ VINORELBINE TARTRATE INJ PORFIMER SODIUM INJECTION CHEMOTHERAPY DRUG Step 20 (history of cardiac transplant) Look back timeframe: N/A ICD-9 Code Description V42.1 HEART REPLACED BY TRANSPLANT September 8, 2014 Copyright Health Information Designs, LLC 23

24 Publication History The Publication History records the publication iterations and revisions to this document. tes for the most current revision are also provided in the Revision tes on the first page of this document. Publication Date tes 01/31/2011 Initial publication and posting to website 09/10/2013 Updated criteria logic and criteria logic diagram for the season Added supporting tables for Steps 3, 4, and 10 09/11/2014 Updated criteria logic and criteria logic diagram for the season Added supporting tables for steps 3, 4, 8, 17, 19, and 20 September 8, 2014 Copyright Health Information Designs, LLC 24