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.