ITEM 

COVERAGE STATUS

I. Drugs

90586, A9600, A9604, J0128, J0594, J0640, J0641, J0780, J0881, J0882, J0885, J0886, J0894, J1094, J1100, J1190, J1200, J1260, J1440, J1441, J1453, J1457, J1626, J1675, J1720, J1940, J2060, J2150, J2278, J2353, J2354, J2355, J2405, J2425, J2430, J2469, J2505, J2765, J2780, J2783, J2820, J2920, J2930, J3240, J3250, J3315, J3410, J3487, J8501, J8510-J8521, J8530, J8540, J8560, J8565, J8597, J8600, J8610, J8650, J8700, J8705, J9000-J9097, J9098, J9100-J9190, J9200-J9293, J9300, J9303, J9305, J9310, J9320-J9390, J9395, J9600, Q0163-Q0181, Q2017, Q2025, Q4081, S0023, S0088, S0091, S0108, S0145, S0146, S0156, S0170, S0172, S0174, S0175, S0176, S0177, S0178, S0179, S0181, S0182, S0183, S0187

Antineoplastic agents which have FDA approval are covered when supplied by a doctor and given by an eligible method of administration.

NOTE: Antineoplastic agents administered in a hospital/facility setting are reimbursed to the facility, unless the cost of the agent is incurred by the doctor.

Coverage for other drugs is determined according to individual or group customer benefits.

Payment should be made for prescription drugs which are ordered and dispensed by a doctor and which relate directly to the treatment of malignant disease.

Chemotherapy should be provided for drugs administered as part of a rescue from, or antidote for, severe toxic reactions to the antineoplastic agent, e.g., Leucovorin given as an antidote following high-dose Methotrexate therapy; diuretics with CisPlatin; or antiemetics.

Payment may be made for oral antiemetic drugs (Q0163-Q0181) when used as full replacement for intravenous antiemetic drugs as part of a cancer chemotherapeutic regimen. Procedure codes Q0166 and Q0180 should not exceed a 24 hour dosage regimen. The remaining codes should not exceed a 48 hour dosage regimen.

Payment should not be made for a rescue agent that is provided in conjunction with the administration of an ineligible antineoplastic drug. In addition, drugs prescribed as dietary supplements, vitamins, sedatives or non- prescription drugs such as aspirin are not covered.

II. Methods of Administration

(50391, 51720, 96360, 96361, 96365-96379, 96401-96450, 96521, 96522, 96523, 96542)

A.  Subcutaneous, intra-muscular, intravenous or intra-arterial injection, infusion or perfusion and intracavitary (e.g., instillation into the bladder via catheter).

Coverage is determined according to individual or group customer benefits.

When multiple drugs are administered concurrently by the same route of administration, only one administration fee will be paid.

When multiple drugs are given sequentially or by different routes of administration, a separate fee will be paid for each administration. This includes rescue agents, etc., described in section I.B. The appropriate administration code should be reported.

NOTE: Instillation of an anti-carcinogenic agent into the bladder (code 51720) is a covered surgical service.

Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy, or ureterostomy tube (e.g., anticarcinogenic or antifungal agent) (code 50391) is a covered surgical service.

Covered as chemosurgical destruction of a malignant lesion when the antineoplastic drug must be applied by the doctor. For chemosurgical destruction, report code 96549.

If the drug is reported on the same day as the topical administration of chemotherapy, and the charges are itemized, combine the charges and pay only the topical administration of chemotherapy.

Payment for the topical administration of chemotherapy performed on the same date of service includes the allowance for the drug. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines. A participating, preferred, or network provider cannot bill the member separately for the drug in this case.

If the drug is reported independently, process it under the appropriate code.

 NOTE: The method of administration is covered only when the drug is eligible for payment.

Generally payment can be made for medical care in conjunction with or as follow-up to chemotherapy provided on an outpatient basis.

Eligible

When drugs are administered into a cavity, e.g., lumbar puncture, peritoneocentesis or thoracentesis, payment will be made for the drug.

However, since the surgical procedure is considered a route of administration, a separate administration allowance will not be made. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

(J7030, J7040, J7042, J7050, J7060, J7070)

Hydration therapy is considered a rescue agent when it is used in conjunction with chemotherapy. When hydration therapy is used for indications other than as a rescue agent, it is subject to the member's therapeutic injection benefit coverage. If the rescue agent is not a benefit of the member's contract, it is not covered. In this instance, a participating, preferred, or network provider can bill the member for the denied service.

Payment is made for medically necessary services.

Supplies used in the administration of chemotherapy are considered part of a provider's overhead expense. Separate payment will not be made for any overhead expense. Coverage for overhead expenses is determined according to individual or group customer benefits. A participating, preferred, or network provider cannot bill the member for these expenses. (Refer to Medical Policy Bulletin Z-39 for additional information on overhead expenses.)