About this policy
Jurisdiction: J5 MAC Part B. States: Iowa, Kansas, Missouri, Nebraska. Type: Active LCD
Coverage indications
This LCD addresses the coverage for chemotherapy agents based on the patient’s condition, the appropriateness of the dose and route of administration, based on the clinical condition, medical necessity and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition. Per this LCD, chemotherapy agents may be covered if reasonable and medical necessity is met AND the drug is FDA approved AND listed in the NCCN Clinical Practice Guidelines in Oncology (NCCN) with the specific ICD-10 diagnosis (that is being treated) for the drug/agent. the chemotherapy agent must be listed Category 1 or 2A in NCCN, the chemotherapy agent must be utilized per the NCCN Recommended Use (order or combination). If the medically accepted indications are listed in one of the other Medicare approved compendia (Micromedex DrugDex as Class I, Class IIa, or Class IIb; American Hospital Formulary Service -Drug Information (AHFS) narrative text is “supportive”; Clinical Pharmacology narrative text is “supportive”; or Lexi-Drugs is listed as “Use Off-Label” and rated as “evidence level A”). A use is not medically accepted if the indication appears in the Medicare approved compendia as: NCCN as Category 3; Micromedex DrugDex as Class III; AHFS narrative text is “not supportive”; Clinical Pharmacology narrative text “not supportive”; or Lexi-Drugs is listed as “use: Unsupported”.
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.
| Code | Code system | Status in this policy |
|---|---|---|
| J9190 | HCPCS | Covered |
| J9215 | HCPCS | Covered |
| J9260 | HCPCS | Covered |
| J9312 | HCPCS | Covered |
| Q5115 | HCPCS | Covered |
| Q5119 | HCPCS | Covered |
| Q5123 | HCPCS | Covered |
| A63.0 | ICD10CM | Covered |
| B07.0 | ICD10CM | Covered |
| B07.8 | ICD10CM | Covered |
| B07.9 | ICD10CM | Covered |
| B27.00 | ICD10CM | Covered |