Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Medicare Part B vs. Part D Crossover Drugs
Policy #:MA08.007s

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company's Medicare Advantage Prescription Drug (MA-PD) and Prescription Drug Plans (PDP) for drugs covered under either the Medicare medical benefit (Part B) or the Medicare pharmacy benefit (Part D) are identified in the chart below.

PLEASE REFER TO THE FOLLOWING ATTACHMENTS FOR ADDITIONAL INFORMATION

Attachment A: Medicare medical benefit (Part B) drugs that can be accessed at a retail or long-term care pharmacy setting. Claims from a retail or long-term care pharmacy process at a medical benefit (Part B) cost share with no pharmacy benefit (Part D) True-Out Of-Pocket (TrOOP) expenses applied.

Attachment B: Drugs that are usually self-administered (defined as a drug that is self-administered more than 50 percent of the time) and excluded from Medicare medical benefit (Part B) coverage

Attachment C: Vaccination and inoculation coverage

Attachment D: Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit (Part B)

Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit (Part B)

Attachment F: Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting
MEDICARE PART B VS. PART D CHART


DRUG CATEGORIES
RULE
PHARMACY BENEFIT ADJUDICATION
MEDICAL
BENEFIT ADJUDICATION
Parenteral Nutrition (TPN)Part B coverage – If the member has a permanent dysfunction of the digestive tract

Part D coverage – All other indications, including dialysis
Administrative Prior Authorization RequiredAdministrative Prior Authorization Required for all home infusion services
Intravenous Immune Globulin (IVIG)Part B coverage – If administered at home for primary immunodeficiency,(please refer to Attachment F for a list of those diagnosis codes that represent primary immunodeficiencies that may be covered under Part B)

Part D coverage If provided in the home for all other indications

Note: Primary immunodeficiencies not included in Attachment F may be reviewed for coverage through applicable Part D benefits.
Administrative Prior Authorization RequiredAdministrative Prior Authorization Required
Inhaled Nebulized Solutions:

acetylcysteine (Mucomyst),
albuterol, albuterol and ipratropium (DuoNeb™), albuterol sulfate (AccuNeb, Proventil®),
arformoterol (Brovana®), budesonide inhalation suspension (Pulmicort Respules®),
cromolyn (Intal®),
dornase alfa (Pulmozyme®),
formoterol fumarate (Performist®),
iloprost (Ventavis®),
ipratropium bromide,
levalbuterol hydrochloride (Xopenex),metaproterenol sulfate (Alupent®),
pentamidine isethionate (NebuPent®),
revefenacin (Yupelri®),
treprostinil (Tyvaso®),
tobramycin inhalation solution (TOBI, Bethkis®)
Part B coverage – If used with a nebulizer in the home setting (Please refer to the specific policy on Nebulizers and Inhalation Solutions for inhalation drugs that may be covered under Part B.)

Part D coverage – If used with a metered dose inhaler or other non-nebulized administration or when used in a long-term care facility
All claims will process as a Part B claim at the point-of-sale. (Pharmacy Claims Process with Medicare Part B cost share with no
True out-of-pocket(TrOOP) expenses applied)
Allow coverage/ payment under the medical benefit
Immunosuppressant:
mycophenolate mofetil (CellCept®), azathioprine (Imuran®, Azasan®), Cyclosporine (Systemic) (Neoral®, Gengraf®), sirolimus (Rapamune®), tacrolimus (Prograf®), Mycophenolic Acid (Myfortic®) and cyclosporine (Sandimmune®); methotrexate,
(Trexall);
basiliximab (Simulect®), belatacept (Nulojix®); Orthoclone OKT3® (muromomab-CD3); Atgam (lymphocyte Immune globulin)
Part B coverage – For beneficiaries who received a transplant from a Medicare-approved facility and were entitled or qualified for Medicare Part A at the time of the transplant

Part D coverage – All other scenarios
Administrative Prior Authorization RequiredAllow coverage/ payment under the medical benefit
Separately billable ESRD Drugs furnished by the dialysis center:
(e.g., Erythropoietin (EPO) [Aranesp®, Epogen®, Procrit®], Lidocaine, Vancomycin, Levocarnitine, Calcitriol)
Part B coverage – Treatment of anemia for members with chronic renal failure (CRF) who are on dialysis

Part D coverage – All other indications
Administrative Prior Authorization RequiredAllow coverage/ payment under the medical benefit
Oral Chemotherapy (Chemo)
Drugs with Intravenous (IV) Equivalent:
e.g., melphalan (Alkeran); methotrexate, (Trexall); etoposide (VePesid®); and capecitabine (Xeloda); topotecan (Hycamtin®); temozolomide (Temodar®); Busulfan (Myleran®); Cyclophosphamide (Cytoxan®)
Part B coverage – Oral chemotherapy agents used in cancer treatment that contain the same active ingredient (or pro-drug) as injectable dosage form that would be covered as: 1) not usually self-administered and 2) provided incident to* a physician's service

Part D coverage – All other oral agents covered
All claims for oral chemotherapy with IV equivalents will process as a Part B claim at the point-of-sale. (Pharmacy Claims Process with Medicare Part B cost share with no TrOOP expenses applied)Allow coverage/ payment under the medical benefit
Oral Anti-Emetic Drugs:
Included but not limited to:
dolasetron mesylate (Anzemet), aprepitant (Emend®)**, granisetron hydrochloride (Kytril®), ondansetron hydrochloride (Zofran®).
Part B coverage – If related to cancer treatment and full replacement for IV administration within 48 hours of cancer treatment

Part D coverage – If it doesn’t meet the rule above, covered under Part D
All claims for oral anti-emetics will adjudicate at the point-of-sale unless the pharmacy or provider indicates Part B coverage.Allow coverage/ payment under the medical benefit
Osteoporosis drugs:
(Forteo, Calcitonin)
Part B coverage For osteoporosis drugs under the following scenario: for women, homebound, with osteoporosis with a bone fracture related to post-menopausal osteoporosis and unable to self administer the injections and the family is unable or unwilling to administer the injections) and when administered by a home health agency

Part D coverage for all other indications
Allow coverage under the pharmacy benefitAdministrative Prior Authorization Required
Products Generally Administered in a Physician’s Office/Clinic (non-self-injectables) (e.g., intramuscular [IM] injections, infusible drugs, or subcutaneous injections [SQ] not usually self-administered)




Part B coverage – If medically necessary and supplied by any of the following: physician, health center/clinic, hospital, critical access hospital (CAH) outpatient department, ambulance, end stage renal disease (ESRD) facilities, comprehensive out-patient rehabilitation facility (CORF), hospital outpatient department (HOPD), Hospital Outpatient Prospective Payment System (OPPS) If it is a self-injectable, allow coverage/ payment at the point-of-saleAllow coverage/ payment under the medical benefit
Drugs that are Considered Supplies (e.g., radiopharmaceuticals, contrast media)Always covered under Part BBenefit exclusion; always reject at the pharmacy point-of-sale as not coveredAllow coverage/ payment under the medical benefit
Antigens

Note: This does not include antibodies (i.e., Xolair®)
Always covered under Part BBenefit exclusion; always reject at the pharmacy point-of-sale as not coveredAllow coverage/ payment under the medical benefit
Blood/Hemophilia Clotting FactorsAlways covered under Part BBenefit exclusion; always reject at the pharmacy point-of-sale as not coveredAllow coverage/ payment under the medical benefit
Drugs Provided with an External Infusion Pump in the Home Setting

Note: Only available for members residing in their home***
Part B coverage For selected drugs in the home setting furnished through a covered external infusion pump (See Attachment E). This does not apply to those drug categories listed in this policy with special rules.

Part D coverage When administered in the home
setting with or without an external infusion pump (e.g., including Intravenous drip, Intramuscular injections, infusion) and does not meet the special rules in Attachment E or when used in a Long Term Care facility.
Allow coverage/payment under the pharmacy benefit for drugs not delivered using DME in the home setting and when administered in a LTC facilityAllow coverage/ payment under the medical benefit when the drug is administered by DME
Prophylactic Vaccines Covered Only under Part B (Influenza and Pneumococcal Vaccine)

Note: The incident-to provision* does not apply to vaccines.
Part B coverage – Influenza and pneumococcal are always covered under Part B

Part D coverage – Never covered under Part D
Deny coverage and refer payment to the medical benefitAllow coverage/ payment under the medical benefit
Prophylactic Vaccines Covered under Both Benefits (Hepatitis B, Tetanus, Rabies, Botulin antitoxin, Antivenin Sera, and Immune Globulin)

Note: The incident-to provision* does not apply to vaccines.
Part B coverage – Tetanus, botulin antitoxin, antivenin sera, immune globulin and rabies vaccines are covered under Part B to treat an injury or as a result of direct exposure to a disease or condition.

Hepatitis B vaccines are covered for intermediate to high-risk individuals for contracting Hepatitis B. (See attachment D for definitions and appropriate diagnosis codes.)

Part D coverageIf it doesn’t meet the rule above, covered under Part D
Administrative Prior Authorization Required for Hepatitis B.

Allow coverage/ payment under the pharmacy benefit for tetanus and rabies.
Allow coverage/payment under the medical benefit for these vaccines when billed with appropriate ICD-10 diagnosis codes.

All other indications deny coverage and refer payment to the pharmacy benefit.
All Other Prophylactic Vaccines

Note: The incident-to provision* does not apply to vaccines.
Part B coverage – Vaccines other than influenza, pneumococcal, hepatitis B, tetanus or rabies are never covered under Part B

Part D coverage – All other prophylactic vaccines for the prevention of illness
Allow coverage/ payment under the pharmacy benefitDeny coverage and refer payment to the pharmacy benefit

* THE INCIDENT-TO-PROVISION
In order to meet all of the general requirements for coverage under the incident-to provision, an FDA-approved drug or biologic must be all of the following:
  • A formulation that is not usually self-administered
  • Furnished by a physician
  • Administered by the physician or by auxiliary personnel employed by the physician and under the physician's personal supervision

The charge, if any, for the drug or biologic must be included in the physician’s bill, and the cost of the drug or biologic must represent an expense to the physician. If the MA organization supplies the drug to the provider, the MA organization will account for the drug under its A/B benefits. If a network pharmacy supplies the drug directly to the beneficiary, the drug will be accounted for under its Part D benefits.

** APREPITANT (EMEND®)
Aprepitant (Emend®) is an oral anti-emetic drug that is approved under Part B when used in combination with a 5-HT3 antagonist and dexamethasone, as a replacement for IV anti-emetic administration.

*** CLARIFICATION ON THE HOME SETTING
In addition to a hospital, a Skilled Nursing Facility (SNF), or a distinct part of a SNF, the following facility or distinct parts of facilities cannot be considered a home for purposes of receiving the Medicare Part B DME benefit:
  • A nursing home that is dually certified as both a Medicare SNF and a Medicaid Nursing Facility (NF)
  • A Medicaid-only NF that primarily furnishes skilled care
  • A non-participating nursing home (i.e., neither Medicare nor Medicaid) that provides primarily skilled care
  • A distinct part of a facility that primarily furnishes skilled care

Policy Guidelines

At the time of this update, this policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

For members enrolled in a Medicare Advantage medical plan who do not have a Part D prescription benefit with the Company, benefits are covered only for drugs eligible under the Part B benefit.

Description

Outpatient prescription drugs are covered for Medicare Advantage members who enroll in a Part D plan. Certain drugs are covered under the medical benefit (Part B) for Medicare Advantage members in accordance with Centers for Medicare & Medicaid Services (CMS) regulations. However, there are prescription drugs that could potentially be covered under either the Part B or the Part D benefit. CMS has provided guidance to resolve potential crossover drug coverage scenarios. This policy provides an overview of the crossover drug scenarios and the procedures for outpatient prescription drug coverage under the Company's Medicare Advantage and stand-alone Prescription Drug Plan (PDP).


MEDICARE MEDICAL BENEFIT (PART B)

Medicare regulations require coverage for outpatient drugs under Part B. Medicare law specifically authorizes coverage for the following Part B drugs when administered on an outpatient basis (see the Medicare Part B vs. Part D Coverage Chart in the Policy section):

  • Antigens (serum)
  • Certain drugs for dialysis, including heparin, erythropoietin (Epogen®), epoetin alfa, darboetin alfa (Aranesp®)
  • Drugs usually not self-administered by the individual (such as intravenous [IV] drugs)
  • Drugs provided with an external infusion pump in the home setting (see Attachment E)
  • Hemophilia clotting factor
  • Immunosuppressive drugs, for individuals who received a transplant from a Medicare-approved facility and were entitled or qualified for Medicare Part A at the time of the transplant
  • Injectable osteoporosis drugs when administered by a home health agency, for women who are homebound, with a bone fracture related to post-menopausal osteoporosis, who are unable to self-administer the injections, and the family is unable or unwilling to administer the injections
  • Intravenous immune globulin when given in the home setting for the indication of primary immunodeficiency (PID) (Please refer to Attachment F for a list of those diagnosis codes that represent primary immunodeficiencies that may be covered under Part B.)
  • Oral anti-cancer drugs for which there is an IV equivalent (provided the IV equivalent is not a self-administered drug and could be administered incident to a physician's professional service)
  • Oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen as a full therapeutic replacement for an IV anti-emetic drug within 48 hours of chemotherapy administration
  • Select drugs taken using durable medical equipment (DME) (such as nebulizers)
  • Select drugs provided in the home setting with an external infusion pump (excludes drugs that do not require an external infusion pump, such as antibiotics)
  • The following prophylactic vaccines:
    • Pneumococcal vaccine
    • Influenza vaccine
    • Hepatitis B vaccine for intermediate- to high-risk individuals (see Attachment D for a definition of high risk)

MEDICARE PHARMACY BENEFIT (PART D)

In general, the definition of a Part D covered drug is contingent upon the following:
  • The drug being available only by prescription
  • The drug being approved by the US Food and Drug Administration (FDA) (unless granted special approval)
  • The drug being used and sold in the United States
  • The drug being used for a medically accepted indication

A drug that is covered under the Medicare hospital benefit (Part A) or medical benefit (Part B), as it is being prescribed and dispensed or administered to an individual, is excluded from the definition of a Part D drug and, therefore, cannot be included in Part D basic coverage.

Examples of drugs that are covered under the Part D benefit include:
  • Biological products not covered under Part B
  • Drugs that are not usually self-administered and provided in the home setting without DME (e.g., intramuscular injection)
  • Self-injected insulin and the supplies necessary for the injection, for those individuals with diabetes at home. This includes syringes, needles, alcohol swabs, and gauze.
  • Prescription drugs not covered under Part B
  • Prescription smoking cessation agents
  • Vaccines not covered under Part B
  • Barbiturates (used in the treatment of epilepsy, cancer, or a chronic mental health disorder)
  • Benzodiazepines

Examples of drugs excluded from the Part D benefit include:
  • Agents used for anorexia, weight loss/gain, fertility, cosmetic/hair growth, prescription cough, and cold products for symptomatic relief
  • Agents used for the treatment of sexual or erectile dysfunction (ED)
  • Less Than Effective (LTE) Drug Efficacy Study Implementation (DESI) drugs
  • Nonprescription/over-the-counter (OTC) drugs
  • Prescription vitamins and minerals (except prenatal, fluoride, and vitamin D analogs)

Benefits may vary based on product line, group, or contract. Individual member benefits must be verified.
References

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2019–20 Influenza Season. [CDC Web site]. 08/23/2019. Available at: https://www.cdc.gov/mmwr/volumes/68/rr/rr6803a1.htm?s_cid=rr6803a1_e&deliveryName=USCDC_921-DM7382. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). 2019-2020 Influenza (Flu) Resources for Health Care Professionals. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19022.pdf. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home. Effective 08/13/2019. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11295.pdf. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. Effective January 1, 2019. MM10871 – Quarterly Influenza Virus Vaccine Code Update-January 2019. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10871.pdf. Accessed January 23, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15, Section 50.4.4.2: Immunizations. [CMS Website]. Effective 07/12/2019. Available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). Decision Memo for Aprepitant for Chemotherapy-Induced Emesis (CAG-00248R). 5/29/2013. Available at:
http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=264. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. [CMS Website]. revised 07/12/2019. Available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Part D Manual. Chapter 6: Part D Drugs and Formulary Requirements. [CMS Website]. 01/15/16. Available at:
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefits-Manual-Chapter-6.pdf. Accessed February 7, 2020.

Centers for Medicare & Medicaid Services (CMS). National Coverage Decision (NCD).110.21: Erythropoiesis stimulating agents (ESAs) in cancer and related neoplastic conditions. [CMS Web site]. 07/30/07. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=322&ncdver=1&bc=BAABAAAAAAAA&. Accessed February 7, 2020.

Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). Vaccines and Immunizations. Recommendations and Guidelines: Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/vaccines/acip/index.html. Accessed February 7, 2020.

Novitas Solutions, Inc. Article (A53127) For Self-Administered Drug Exclusion List. [Novitas Medicare Services Web site]. Original:10/01/2015, Revised: 12/02/2019.  Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53127&ver=88&Keyword=self+administered&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC%7cSAD%7cRTC%7cReg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&search_id=&service_date=&bc=IAAAABAAAAAA&. Accessed February 7, 2020.

Novitas Solutions, Inc. Local Coverage Determination (LCD)L35093 - Intravenous Immune Globulin (IVIG). [Novitas Solutions Web site]. Original:10/01/2015, Revised:11/14/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35093&ver=100&Keyword=ivig&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC%7cSAD%7cRTC%7cReg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAABAAAAAA& . Accessed February 7, 2020.

Novitas Solutions, Inc. Article (A56786) Billing and Coding: Intravenous Immune Globulin (IVIG). [Novitas Medicare Services Web site]. Original: 08/08/2019, Revised: 12/02/2019.  Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53127&ver=88&name=331*1&UpdatePeriod=855&bc=AAAAEAAAAAAA&. Accessed February 7, 2020.

Novitas Solutions, Inc. Article (A53127) For Self-Administered Drug Exclusion List. [Novitas Medicare Services Web site]. Original:10/01/2015, Revised: 12/02/2019.  Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53127&ver=88&name=331*1&UpdatePeriod=855&bc=AAAAEAAAAAAA&. Accessed February 7, 2020.

Noridian. Local Coverage Determination (LCD): External Infusion Pumps (L33794). Original:10/01/2015, Revised: 05/31/2020. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33794&ContrId=389. Accessed April 20, 2020.

Noridian. Local Coverage Article for External Infusion Pumps - Policy Article (A52507). Original:10/01/2015, Revised: 05/31/2020. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52507. Accessed April 20, 2020.

Noridian Heathcare Solutions, LLC., Local Coverage Determination (LCD). L33370: Nebulizers. Original: 10/01/15. Revised: 05/17/2020). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33370&ver=30&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=6&KeyWord=Nebulizers&KeyWordLookUp=Title&KeyWordSearchType=Exact&Date=05242020&kq=true&bc=EAAAABAAAAAA& . Accessed April 16, 2020.

Noridan Healthcare Solutions, LLC. Local Coverage Article: Nebulizers - Policy Article (A52466). Original:10/01/15. (Revised: 05/17/2020). Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52466. Accessed April 16, 2020.

Noridian. Local Coverage Determination (LCD): Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) (L33827). Original:10/01/2015. Revised: 01/01/2019. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Oral+Antiemetic+Drugs/e7e5dcff-5caf-4fa1-af02-13f0ab4b7efc. Accessed February 7, 2020.

Noridian. Local Coverage Determination (LCD): Immunosuppressive Drugs (L33824). Original:10/01/2015. Revised: 01/01/2020. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Immunosuppressive+Drugs+LCD+and+PA/7da928ab-6d21-461c-903b-bea52fc0fbb3. Accessed February 7, 2020.

Noridian. Local Coverage Determination (LCD): Parenteral Nutrition (L33798). Original: 10/01/2015, Revised: 01/01/2019. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Parenteral+Nutrition+LCD+and+PA/1b7429bc-6645-41dc-8167-88a15ffed946. Accessed February 7, 2020.

Noridian. Local Coverage Determination (LCD): Intravenous Immune Globulin (L33610). Original: 10/01/2015, Revised: 01/01/2020. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Intravenous+Immune+Globulin+LCD/39082f12-2409-4bbc-9947-2ae5639f453f. Accessed February 7, 2020.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Influenza Virus Vaccine Safety and Availability [FDA Web site]. 03/22/2018. Available at: https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/influenza-virus-vaccine-safety-availability. Accessed February 7, 2020.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachments


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachments


Revenue Code Number(s)

N/A


Misc Code

:


TO REPORT SUBCUTANEOUS ROUTE OF ADMINISTRATION, APPEND THE FOLLOWING MODIFIER:

JB Administered Subcutaneously



Coding and Billing Requirements


Cross References

Attachment A: Medicare Part B vs. Part D Crossover Drugs
Description: Part B drugs that can be accessed through the Part D pharmacy benefit: pharmacy claims process at Medicare Part B cost share with no true out-of-pocket (TrOOP) expenses applied

Attachment B: Medicare Part B vs. Part D Crossover Drugs
Description: Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage

Attachment C: Medicare Part B vs. Part D Crossover Drugs
Description: Vaccination and inoculation coverage.

Attachment D: Medicare Part B vs. Part D Crossover Drugs
Description: Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit (Part B).

Attachment E: Medicare Part B vs. Part D Crossover Drugs
Description: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B

Attachment F: Medicare Part B vs. Part D Crossover Drugs
Description: Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting



Related Documents


Database 'Medicare Advantage', View 'Medical Policy News Flash DRAFTS', Document 'Flumist® Intranasal Live Attenuated Influenza Vaccine'Newsflash Topic: Flumist® Intranasal Live Attenuated Influenza Vaccine



Policy History

MA08.007s:
07/01/2020This policy has been identified for the HCPCS code update, effective 07/01/2020.

The following HCPCS code has been added to Attachment E of this policy
  • J1558

REVISIONS FROM MA08.007r:
06/08/2020This version of the policy will become effective 06/08/2020.

The following revisions have been made to the MEDICARE PART B VS. PART D CHART regarding Nebulized Inhalation Solutions to communicate when Part B coverage applies.
  • The following inhalation solutions may be covered under Part B coverage if used with a nebulizer in the home setting. (Please refer to the specific policy on Nebulizers and Inhalation Solutions for inhalation drugs that may be covered under Part B.):
  • pentamidine isethionate (NebuPent®)
  • aformoterol (Brovana®)
  • formoterol fumarate (Performist®)
  • treprostinil (Tyvaso®)
  • iloprost (Ventavis®)
  • revefenacin (Yupelri®)
The following inhalation solution was added to Attachment A of this policy (Medicare medical benefit (Part B) drugs that can be accessed at a retail or long-term care pharmacy setting. Claims from a retail or long-term care pharmacy process at a medical benefit (Part B) cost share with no pharmacy benefit (Part D) True-Out Of-Pocket (TrOOP) expenses applied:
  • revefenacin (Yupelri®)
The following HCPCS codes were added to Attachment E for the administration of pooled plasma derivative, subcutaneous immune globulin for the treatment of documented primary immune deficiency disease (Please refer to the specific policy on Immune Globulin: Intravenous (IVIG).):
J1555 INJECTION, IMMUNE GLOBULIN (CUVITRU), 100 MG
J1575 INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN
J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME [Xembify®]

REVISIONS FROM MA08.007q:
01/01/2020This policy has been identified for the annual CPT code update effective 01/01/2020.

The following CPT code has been added to attachment C of this policy:

90694

REVISIONS FROM MA08.007p:
12/02/2019This version of the policy will become effective 12/02/2019.

The following criterion for Intravenous Immune Globulin (IVIG) has been revised to communicate when Part B coverage applies:
  • Part B coverage- If administered at home for primary immunodeficiency, (please refer to Attachment F for a list of those diagnosis codes that represent primary immunodeficiencies that may be covered under Part B)
The following criterion for IVIG has been revised to communicate when Part D coverage applies:
  • Part D coverage – If provided in the home for all other indications.
Note: Primary immunodeficiencies not included in attachment F may be reviewed for coverage through applicable Part D benefits.

Attachment F added to the policy to convey Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting.

The following ICD-10 diagnosis codes were added to Attachment F of this policy:

D80.0, D80.2, D80.3, D80.4, D80.5
D80.6, D80.7, D81.0, D81.1, D81.2

D81.5, D81.6, D81.7, D81.89, D81.9
D82.0, D82.1, D82.4, D83.0, D83.1
D83.2, D83.8, D83.9, G11.2

The following drugs that are usually self- administered were added to Attachment B of this policy:

Actemra J3262 subcutaneous route
Aimovig C9399, J3490, J3590
Ajovy J3031
Benlysta J0490 subcutaneous route
Cyltezo C9399, J3490, J3590
Emgality C9399, J3490, J3590
Kevzara C9399, J3490, J3590
Lantus Solostart C9399, J3490, J3590
Orencia J0129 subcutaneous route
Ozempic C9399, J3490, J3590
Takhzyro J0593
Tymlos J3590

For drugs that have more than one method of administration, application of the JA or JB modifier is required to indicate the route of administration.
  • To report the intravenous route of administration, append the following modifier:
JA Administered Intravenously
  • To report the subcutaneous route of administration, append the following modifier:
JB Administered Subcutaneously

Drug codes that must use HCPCS modifier JB when the subcutaneous form of the drug is administered are listed with an asterisk * in the Coding Table of Attachment B if this policy.

REVISIONS FROM MA08.007o:
07/01/2019This policy has been identified for the CPT code update, effective 07/01/2019.

The following CPT code has been added to Attachment C, of this policy as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • 90619

The following CPT code narrative has been revised in Attachment C of this policy: 90734

REVISIONS FROM MA08.007n:
02/25/2019This version of the policy will become effective 02/25/2019.

The following changes have been made to Attachment C of this policy (Vaccination and inoculation coverage).
  • The Company’s coverage position has changed from Experimental/Investigational to covered for the following CPT code 90660.
  • The Company’s coverage position for CPT code 90697 has changed from covered under Part B, regardless of whether the vaccine is ordered by a doctor of medicine or osteopathy, to never covered under Part B and are only covered under Part D.

The following changes have been made to Attachment D of this policy (Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit [Part B]).
  • The following ICD-10 codes have been added:
    D68.0, F11.10, F11.11, F11.120, F11.121F11.122, F11.129, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F13.10, F13.11, F13.120, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F16.10, F16.11, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, I12.0, I13.11, I13.2, Z20.5, Z72.52
  • The following ICD-10 codes have been deleted:
    F12.20, F12.21, F12.220, F12.221, F12.222, F12.229, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F18.10, F18.11, F18.121, F18.129, F18.14, F18.150, F18.120, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.21, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F55.0, F55.1, F55.2, F55.4, F55.8, F66, F72, F73, F78, F79, Q90.0, Q90.1, Q90.2, Q90.9

REVISIONS FROM MA08.007m:
01/01/2019This policy has been identified for the CPT code update, effective 01/01/2019.

The following CPT code has been added to Attachment C of this policy as experimental/investigational because there is no US Food and Drug Administration (FDA) approval for this vaccine at this time:
  • 90689

REVISIONS FROM MA08.007l:
10/08/2018This version of the policy will become effective 10/08/2018.

The Company’s coverage position has changed from Not Medically Necessary to Medically Necessary on the use of the nasal spray influenza vaccine (LAIV4) during the 2018–19 influenza season based on the Advisory Committee on Immunization Practices (ACIP) recommendation.

The following diagnoses for primary immune deficiency (PID) were removed from the description section and from Attachment E of this policy with reference made to: (Please refer to the specific policy on Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
  • Congenital hypogammaglobulinemia
  • Immunodeficiency with increased IGM
  • Common variable immunodeficiency
  • Wiskott-Aldrich syndrome
  • Combined immunity deficiency

REVISIONS FROM MA08.007k:
07/30/2018This version of the policy will become effective 07/30/2018.

The following drug was added to Attachment B of this policy:

C1 esterase inhibitor (human)
Haegarda
C9399, J3490, J3590
Unclassified drugs or biologicals
Unclassified drugs
Unclassified biologics


The following CPT code has been deleted from attachment C of this policy:
90703.

The following HCPCS code has been deleted from attachment B of this policy:
J1817 Insulin for administration through DME (ie, insulin pump) per 50 units

The following HCPCS code has been added to attachment E of this policy:
J9039 Injection, blinatumomab, 1 microgram

The following indication has been added to attachment E of this policy for Blinatumomab (J9039):
  • Minimal residual disease positive (MRD+) B-cell acute lymphoblastic leukemia (B-ALL)

REVISIONS FROM MA08.007j:
01/01/2018 This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT code has been added to Attachment C, of this policy: 90756
    The following changes were made through a newsflash:
    • The following codes were moved from E/I to MN in Attachment C: 90750, 90739 and will follow the policy benefit coverage criteria

REVISIONS FROM MA08.007i:
11/17/2017Added to Attachment A: PART B DRUGS ACCESSED AT A RETAIL OR LONG-TERM CARE PHARMACY SETTING. CLAIMS PROCESS AT A MEDICAL BENEFIT (PART B) COST SHARE WITH NO PHARMACY BENEFIT (PART D) TRUE-OUT-OF-POCKET (TROOP) EXPENSES APPLIED.
  • Heparin and saline flushes


The following drugs were added to Attachment B (Drugs self administered and excluded under part B:

J0800: H.P. Acthar® Gel; J0364: Apokyn; C9399, J3490, J3590, Amjevita™; C9399, J3490, J3590: Dupixent®; C9399, J3490, J3590: Erelzi™; C9399, J3490, J3590: Kynamro®; C9399, J3490, J3590: Orencia®; C9399, J3490, J3590: Quad-Mix; C9399, J3490, J3590: Rasuvo®; C9399, J3490, J3590: Siliq™.

The following brand name drugs were added for the following CPT/HCPCS codes: J1595: Glatopa; J1830: Extavia; J2941: Omnitrope, Zomacton™, Zorbtive; J3030: Sumavel® Dosepro®, Zembrace; C9399, J3490, J3590: Pegasys® Proclick™.

Attachment D the following codes were added:

F18.11 Inhalant abuse, in remission
F19.11 Other psychoactive substance abuse, in remission

REVISIONS FROM MA08.007h:
10/01/2017This policy has been identified for the ICD-10 code update, effective 10/01/2017.

The following ICD-10 codes has been added to this policy to Attachment D.
    E11.10 Type 2 diabetes mellitus with ketoacidosis without coma
    E11.11 Type 2 diabetes mellitus with ketoacidosis with coma

REVISIONS FROM MA08.007g:
07/01/2017This policy has been identified for the CPT code update, effective 07/01/2017.

The following CPT codes have revised narratives: 90620, 90621, 90651

The following CPT code has been added to this policy; in Attachment C: 90587

REVISIONS FROM MA08.007f:
01/01/2017The following policy requirements have been revised:

Attachment B: Drugs that are usually self-administered (defined as a drug that is self-administered more than 50 percent of the time) and excluded from Medicare medical benefit (Part B).Attachment B

The following drugs were added in accordance with Medicare.

J3355 Bravelle
C9399, J3590 Byetta
C9399, J3490, J3590 Bydureon
C9399: Cosentyx®;
C9399, J3490, J3590: Egrifta®;
J1744 Firazyr
C9399, J3490, J3590 Myalept™ 
C9399, J3490, J3590: Natpara®
C9399, J3590: Otrexup™
C9399, J3490, J3590: Plegridy®;
C9399, J3490, J3590: Praluent®;
C9399, J3490, J3590: Repatha™
C9399, J3490, J3590: Rebif®
J2212, Relistor;
C9399, J3490: Saxenda
C9399, J3490, J3590 SIGNIFOR®;
C9399, J3490, J3590: Simponi®;
C9399, J3490, J3590: Strensiq®;
C9399, J3490, J3590 Sylatron
C9399, J3490, J3590: Taltz ®
C9399, J3490, J3590 Tanzeum
C9399, J3490 Toujeo®;
J3590: TriMix;
C9399, J3490: Trulicity®;
C9399, J3490, J3590: Victoza
C9399, J3490, J3590: Zinbryta™

Attachment C:

The following CPT codes have been added to this policy: 90674, 90682, 90750

The following CPT codes have revised narratives: 90655, 90656, 90657, 90658, 90661, 90685, 90686, 90687, 90688, 90698 and 90734.

Attachment E: Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit (Part B).
  • The following criteria were revised;
      For the administration of parenteral inotropic therapy using the drugs; dobutamine (J1250), milrinone (J2260) or dopamine (J1265) for individuals with American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Stage D heart failure (HF) or New York Heart Association (NYHA) Class IV HF.
  • The following codes are deleted codes J9110, J9375, J9380 and have been removed from Attachment E
  • J1562 Injection, immune globulin (Vivaglobin), 100 mg is no longer on the market and is being removed from the policy

REVISIONS FROM MA08.007e:
10/01/2016 This policy has been identified for the ICD-10 CM code update, effective 10/01/2016
The following ICD-10 CM codes have been revised in this policy:

FROM: O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
TO: O24.011 Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester

FROM: O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
TO: O24.012 Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester

FROM; 24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
TO; O24.013 Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester

TO; O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester
FROM; O24.019 Pre-existing type 1 diabetes mellitus, in pregnancy, unspecified trimester

FROM; 24.02 Pre-existing diabetes mellitus, type 1, in childbirth
TO; O24.02 Pre-existing type 1 diabetes mellitus, in childbirth

FROM; O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium
TO; O24.03 Pre-existing type 1 diabetes mellitus, in the puerperium

FROM; O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
TO; O24.111 Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester

FROM; O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
TO; O24.112 Pre-existing type 2 diabetes mellitus, in pregnancy, second trimester

FROM; O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
TO; O24.113 Pre-existing type 2 diabetes mellitus, in pregnancy, third trimester

FROM; O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
TO; O24.119 Pre-existing type 2 diabetes mellitus, in pregnancy, unspecified trimester

FROM: O24.12 Pre-existing diabetes mellitus, type 2, in childbirth
TO: O24.12 Pre-existing type 2 diabetes mellitus, in childbirth

FROM: O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium
TO: O24.13 Pre-existing type 2 diabetes mellitus, in the puerperium
  • The following ICD-10 CM codes have been deleted from this policy:
    E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359,E09.321, E09.329, E09.331, E09.339 E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331 E10.339, E10.341, E10.349 E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359
  • The following ICD-10 CM codes have been added to this policy:
    E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.3391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513 E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539 E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E08.37X1, E08.37X2, E08.37X3, E08.37X9, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313, E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E09.37X1, E09.37X2, E09.37X3, E09.37X9, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.37X1 E10.37X2, E10.37X3, E10.37X9, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531 E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, 13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.37X1, E13.37X2, E13.37X3, E13.37X9, O24.415, O24.425, O24.435.

REVISIONS FROM MA08.007d:
01/01/2016Inclusion of a policy in a Code Update does not imply that a full review of the policy was completed at this time.

Medical Policy # MA08.007d; Medicare Part B vs. Part D Crossover Drugs
This policy has been identified for the CPT / HCPCS code update, effective 01/01/2016.

The following HCPCS code has been added to this policy:

J7340: Carbidopa 5 mg/levodopa 20 mg enteral suspension

The following CPT code has been added to this policy:

90625: Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use

The following CPT narratives have been revised in this policy:

90620
FROM: Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, 2 dose schedule, for intramuscular
TO: Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B (memb), 2 dose schedule, for intramuscular

90621
FROM: Meningococcal recombinant lipoprotein vaccine, Serogroup B, 2 or 3 dose schedule, for intramuscular use
TO: Meningococcal recombinant lipoprotein vaccine, Serogroup B (memb), 3 dose schedule, for intramuscular use

90644
FROM: Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use

TO: Meningococcal conjugate vaccine, serogroups c & y and hamophilus influenza type b vaccine (hib-mency), 4 dose schedule, when administered to children 2-18 months of age, for intramuscular use
90647
FROM: Haemophilus influenzae b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, for intramuscular use
TO: Hamophilus influenza type b vaccine (hib), prp-omp conjugate, 3 dose schedule, for intramuscular use

90648
FROM: Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for intramuscular use
TO: Hamophilus influenza type b vaccine (hib), prp-t conjugate, 4 dose schedule, for intramuscular use

90649
FROM: Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (HPV4), 3 dose schedule, for intramuscular use
TO: Human papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vhpv), 3 dose schedule, for intramuscular use

90650
FROM: Human Papilloma virus vaccine, types 16, 18, bivalent (HPV2), 3 dose schedule, for intramuscular use
TO: Human papillomavirus vaccine, types 16, 18, bivalent (2vhpv), 3 dose schedule, for intramuscular use

90651
FROM: Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use
TO: Human papillomavirus vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vhpv), 3 dose schedule, for intramuscular use

90698
FROM: Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenzae Type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use
TO: Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenzae type b, and inactivated poliovirus vaccine, (dtap -ipv/hib), for intramuscular use

90739
FROM: Hepatitis B vaccine (HepB), adult dosage (2 dose schedule), for intramuscular use
TO: Hepatitis b vaccine (hepb), adult dosage 2 dose schedule, for intramuscular use

90748
FROM: Hepatitis B and Haemophilus influenzae b vaccine (Hib-HepB), for intramuscular use
TO: Hepatitis b and hamophilus influenza type b vaccine (hib-hepb), for intramuscular use


The following CPT codes have been deleted from this policy: These vaccines are no longer available.

90645 Hemophilus influenza b vaccine (HIB), HBOC conjugate (4 dose schedule), for intramuscular use
90646 Hemophilus influenza b vaccine (HIB), PRP-D conjugate, for booster use only, intramuscular use
90669 Pneumococcal conjugate vaccine, 7 valent (pcv7), for intramuscular use
90692 Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use
90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. Military)
90703 Tetanus toxoid adsorbed, for intramuscular use
90704 Mumps virus vaccine, live, for subcutaneous use
90705 Measles virus vaccine, live, for subcutaneous use
90706 Rubella virus vaccine, live, for subcutaneous use
90708 Measles and rubella virus vaccine, live, for subcutaneous use
90712 Poliovirus vaccine, (any type[s]) (OPV), live, for oral use
90719 Diphtheria toxoid, for intramuscular use
90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and haemophilus influenzae b vaccine (dtwp-hib), for intramuscular use
90721 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and haemophilus influenzae b vaccine (dtap/hib), for intramuscular use
90725 Cholera vaccine for injectable use
90727 Plague vaccine, for intramuscular use
90735 Japanese encephalitis virus vaccine, for subcutaneous use
S0195 Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from five years to nine years of age who have not previously received the vaccine

REVISIONS FROM MA08.007c:
10/01/2015 ICD-10-CM codes, that were added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

REVISIONS FROM MA08.007b:
07/01/2015 This policy has been identified for the CPT code update, effective 07/01/2015.

The following CPT code narratives have been revised in this policy:

90632, 90633, 90634, 90644, 90647, 90648, 90649, 90650, 90653, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90666, 90667, 90668, 90669, 90670, 90672, 90673, 90680, 90681, 90685, 90686, 90687, 90688, 90696, 90698, 90702, 90714, 90716, 90720, 90721, 90732, 90733, 90734, 90736, 90739, 90740, 90743, 90744, 90746, 90747, 90748.

REVISIONS FROM MA08.007a:
4/22/2015This version of the policy will become effective 04/22/2015.

The following revisions occurred with this update:

Attachment A
  • The list of Drugs found in Attachment A has been revised.

Attachment C
  • The following policy requirements have been revised:
    • 90630 (to eligible)
  • The following CPT codes have been added to this policy:
    • 90620, 90621

Attachment D:
  • The following criterion has been added to this policy:
    • Diabetes mellitus added; as an indication for high risk groups for the Hepatitis B vaccine:
      • Added diagnosis codes to support the newly added indication

Attachment G
  • The following criterion has been added to this policy:
    • 2 additional drugs covered on an external infusion pump with criteria: Levodopa-Carbidopa enteral suspension and Blinatumomab

Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

REVISIONS FROM MA08.007:
01/01/2015This is a new policy.

Note: On 12/18/2014, this policy was identified for the CPT code update, effective 01/01/2015.

The following CPT code has been added to this policy (Part D).
  • 90651

The following CPT codes has been added to this policy as experimental/investigational.
  • 90630
  • 90697

The following CPT codes have been revised in this policy:
  • 90654
  • 90721
  • 90723
  • 90734

The following HCPCS codes have been deleted from this policy:
  • J2271
  • J2275





Version Effective Date: 07/01/2020
Version Issued Date: 07/01/2020
Version Reissued Date: N/A