TRICARE Manuals - Display Chap 7 Sect 2.7 (Change 109, Apr 27, 2023)

Medicine

Chapter 7

Section 2.7

Hydration, Therapeutic, Prophylactic, And Diagnostic Injections And Infusions

Issue Date:

Authority: 32 CFR 199.4(b)(2)(v), (b)(3)(iii), (b)(5)(v), (d)(3)(vi), (e)(11)(ii), and (g)(15)

Revision: C-1, March 10, 2017

1.0 CPT PROCEDURE CODES

96360 - 96379

2.0 HCPCS PROCEDURE CODES

J2357, J3487, J3488

3.0 DESCRIPTION

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.

4.0 POLICY

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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