Mountain State Medical Policy Bulletin
Section: Injections
Number: I-42
Topic: Zoledronic Acid(Zometa®)
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Zoledronic acid (Zometa) is FDA approved for the following indications:

  1. The treatment of hypercalcemia of malignancy (275.42).
  2. The treatment of multiple myeloma (203.00-203.01).
  3. The treatment of bone metastases from solid tumors in conjunction with standard anti-neoplastic therapy, including bone metastases from multiple myeloma, breast carcinoma, prostate carcinoma, and other solid tumors (162.0-162.9, 170.0-170.9, 174.0-174.9, 175.0-175.9, 185, 189.0-189.9, 193, 195.0, 197.0, 198.0, 198.5, 198.81, 198.82).
NOTE:
Prostate cancer should have progressed after treatment with at least one hormonal therapy.

The recommended dose for the treatment of hypercalcemia is 4 mg in 100 ml solution, given as a single dose over no less than 15 minutes.

The recommended dose for the treatment of bone metastases from solid tumors or multiple myeloma is 4 mg in 100 ml solution, infused over no less than 15 minutes every three to four weeks.

The use of zoledronic acid for any other diagnosis not listed in the coverage criteria above is considered experimental/investigational, and therefore, not covered. A participating, preferred, or network provider can bill the member for the denied service.

Coverage for zoledronic acid is determined according to individual or group customer benefits. Zoledronic acid is not reimbursable under the prescription drug benefit.

Description

Zoledronic acid inhibits bone resorption.  The antiresorptive mechanism is not fully understood and several factors are thought to contribute to this action. In vitro, zoledronic acid inhibits osteoclastic activity and induces osteoclast apoptosis. Osteoclastic resorption of mineralized bone and cartilage through its binding to bone is blocked by zoledronic acid. Increased osteoclastic activity and skeletal calcium release induced by various stimulatory factors released by tumors are inhibited by zoledronic acid.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

J3487     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious life-threatening condition and when medically necessary and appropriate for the patient’s condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

08/2005,  Zoledronic covered for certain diagnoses

References

Zometa® (Zoledronic Acid) package insert; Novartis Pharmaceutical Corporation, East Hanover, NJ, 04/2005

Zoledronic Acid, USPDI, Vol. I, Edition 24, 2004 Micromedex, Inc.

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.