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.