About this policy
On May15, 2013, the U. S. Food and Drug Administration (FDA) approved radium Ra 223 dichloride (Xofigo ® Injection, Bayer HealthCare Pharmaceuticals Inc.) for the treatment of patients with castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease. Xofigo ® is an alpha-particle emitting radiotherapeutic drug which mimics calcium and forms complexes with hydroxyapatite at areas of increased bone turnover, such as bone metastases. The recommended dose and schedule for Xofigo ® is 55 kBq /k g (1.49 microcurie s/kg ) administered by slow intravenous injection over 1 minute every 4 weeks for 6 doses. Submit: HCPCS code A9606 Diagnoses: ICD-10 code C61 - Malignant neoplasm of prostate and C79.51 - Secondary malignant neoplasm of bone OR C79.52 - Secondary malignant neoplasm of bone marrow Narrative field or electronic equivalent state "visceral metastases are absent".
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.