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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 7
Section 2.7
Hydration, Therapeutic, Prophylactic, And Diagnostic Injections And Infusions
Issue Date:  
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-1, March 10, 2017
96360 - 96379
J2357, J3487, J3488
Intravenous (IV) hydration infusion consists of pre-packaged fluid and electrolytes, but not infusion of drugs or other substances. A therapeutic, prophylactic, or diagnostic IV infusion or injection (other than hydration) is for the administration of substances or drugs.
Note:  Policy regarding chemotherapy administration is found in Section 16.3.
4.1  Hydration IV infusion consisting of a pre-packaged fluid and electrolytes is covered.
4.2  Intravenous or intra-arterial push (an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient or an infusion of 15 minutes or less) for therapy, prophylactic, or diagnosis is covered.
4.3  Off-label use of zoledronic acid (Zometa®) for the treatment of breast cancer may be cost-shared when:
4.3.1  Patient was premenopausal at the time of diagnosis, and has stage I or II breast cancer;
4.3.2  Patient has had surgically induced menopause (e.g., oophorectomy) or has been put temporarily into menopause (chemically induced menopause with Goserelin or similar product) prior to administration of zoledronic acid;
4.3.3  Patient has hormone receptor (Estrogen Receptor (ER) and/or Progesterone Receptor (PR)) positive disease and zoledronic acid is being used in combination with hormonal therapy (e.g., Tamoxifen, Arimedex®, Aromasin®, Femara®);
4.3.4  No concurrent adjuvant chemotherapy has been given or planned;
4.3.5  Prescriber is an oncologist or an individual highly familiar with prescribing and monitoring of oncology-related medications.
4.3.6  Off-label use of omalizumab (Xolair®) for the treatment of chronic urticaria may be cost-shared.
5.0  EFFECTIVE Dates
5.1  February 12, 2009, for off-label use of zoledronic acid (Zometa®) for the treatment of breast cancer.
5.2  July 1, 2011, for off-label use of omalizumab (Xolair®) for the treatment of chronic urticaria.
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