1.0 CPT 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 may be
covered for cancer and non-cancer diagnoses when medically necessary
and appropriate and when it otherwise meets program requirements
(see, for examples, Chapter 1, Section 2.1 regarding
unproven drugs, devices, medical treatments and procedures and the
hierarchy of reliable evidence; Chapter 1, Section 3.1 for
the standard for determining coverage for rare diseases; and Chapter 8, Section 9.1, paragraph 3.3.3 for
the standard determining coverage for off-label use.). In determining
coverage, the contractor will consider United States (U.S.) Food
and Drug Administration (FDA) labeled indications, National Comprehensive Cancer
Network (NCCN) recommendations, and other reliable evidence, as
appropriate for the diagnosis at issue.
3.2 Chemotherapy administration,
subcutaneous or intramuscular; non-hormonal and anti-neoplastic
is covered.
3.3 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.
3.4 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 eight hours requiring
use of a portable or implantable pump and each additional sequential
infusion (different substance/drug) up to one hour) is covered.
3.5 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.
3.6 Chemotherapy administration
into pleural cavity, requiring and including thoracentesis; into
the peritoneal cavity requiring and including peritoneocentesis
is covered.
3.7 Chemotherapy administration
into Central Nervous System (CNS) (e.g., intrathecal requiring and including
spinal puncture) is covered.
3.8 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.
3.9 Irrigation of implanted venous
access device for drug delivery systems is covered.
3.10 Chemotherapy injection, subarachnid
or intraventricular via subcutaneous reservoir, single or multiple agents
is covered.
3.11 Paclitaxel
(Taxol)
is and paclitaxel protein-based particles
are 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 United States (US) 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.
