1.0 CPT
PROCEDURE CODES
96401, 96402, 96405, 96406,
96409, 96411, 96413, 96415 - 96417, 96420, 96422, 96423, 96425, 96440,
96445, 96450, 96521 - 96523, 96542, 96549
3.0 POLICY
3.1 Chemotherapy
administration, subcutaneous or intramuscular; non-hormonal and
anti-neoplastic is covered.
3.2 Chemotherapy administration,
intralesional, up to and including seven lesions, more than seven
lesions, intravenous push technique, single, initial substance/drug,
each additional substance/drug is covered.
3.3 Chemotherapy administration,
intravenous infusion technique; up to one hour, single or initial substance/drug;
each additional hour, initiation of prolonged chemotherapy infusion
(more than 8 hours requiring use of a portable or implantable pump
and each additional sequential infusion (different substance/drug)
up to one hour) is covered.
3.4 Chemotherapy administration,
intra-arterial; push technique/infusion technique, up to one hour;
infusion technique, each additional hour up to eight hours infusion
technique (more than eight hours) requiring the use of a portable
or implantable pump is covered.
3.5 Chemotherapy administration
into pleural cavity, requiring and including thoracentesis; into the
peritoneal cavity requiring and including peritoneocentesis is covered.
3.6 Chemotherapy
administration into Central Nervous System (CNS) (e.g., intrathecal
requiring and including spinal puncture) is covered.
3.7 Refilling
and maintenance of portable pump is covered. Refilling and maintenance
of implantable pump or reservoir for drug delivery, systemic (e.g.,
intravenous-intera arterial) is covered.
3.8 Irrigation of implanted venous
access device for drug delivery systems is covered.
3.9 Chemotherapy
injection, subarachnid or intraventricular via subcutaneous reservoir,
single or multiple agents is covered.
3.10 Paclitaxel (Taxol) is covered
for the treatment of breast cancer for the following indications (Healthcare
Common Procedure Coding System (HCPCS) code J9265). This is not
all inclusive. Other U.S. Food and Drug Administration (FDA)-approved
labeled indications of Taxol are also covered):
3.10.1 Adjuvant
therapy for node-positive breast cancer when administered sequentially following
standard Doxorubicin-containing combination chemotherapy.
3.10.2 Adjuvant
therapy for early-stage breast cancer.
3.10.3 First-line
therapy for metastatic breast cancer.
• Paclitaxel alone or
in combination with Anthracycline (Doxorubicin, Epirubicin) for Anthracycline-naive
patients.
• Paclitaxel
for Anthracyline-resistant patients.
• Paclitaxel and Gemcitabine
following failure of adjuvant chemotherapy.
• Paclitaxel and Trastuzumab
(Herceptin®) for HER-2-positive breast cancer.
• Paclitaxel and Bevacizumab
(Avastin™) for HER-2-negative breast cancer.
• Paclitaxel and Carboplatin
for HER-2-positive breast cancer.
3.10.4 Second-line
therapy for advanced breast cancer for the treatment of breast cancer
in patients who have metastatic disease refractory to conventional
combination chemotherapy or who have experienced relapse within
six months of adjuvant chemotherapy; prior therapy should have included
an Anthracycline agent unless clinically contraindicated.
3.11 Paclitaxel
protein-bound particles (Abraxane) (HCPCS code J9264) is covered
for the treatment of breast cancer after failure of combination
chemotherapy for metastatic breast cancer or relapse within six
months of adjuvant chemotherapy. (This is not all inclusive. Other
FDA-approved labeled indications are also covered.)
3.12 Cytoreductive Surgery (CRS) with
Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for treatment
of Peritoneal Carcinomatosis (PC) secondary to colorectal cancer
is proven.
4.0 EFFECTIVE
DATES
4.1 October
25, 1999 for Paclitaxel (Taxol).
4.2 January 7, 2005, for Paclitaxel protein-bound
particles (Abraxane).
4.3 CRS
with HIPEC for treatment of PC secondary to colorectal cancer is
covered effective February 1, 2017.