Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.007q


Attachment:E

Policy #:MA08.007q

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

Title:Medicare Part B vs. Part D Crossover Drugs


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.



INDICATIONS FOR WHEN SELECTED DRUGS THAT ARE BEING ADMINISTERED ON AN EXTERNAL INFUSION PUMP ARE COVERED UNDER THE MEDICARE MEDICAL BENEFIT (PART B)


Medicare authorizes coverage under the medical Part B benefit for selected drugs furnished through a covered external infusion pump in the home setting. This attachment does not supersede the drug categories listed in the Medicare Part B vs. Part D Coverage Issues Chart listed in the policy for the purposes of an external infusion pump. The following indications for treatment using external infusion pumps are covered under the medical Part B benefit. For more information on the medically necessary criteria for the following drugs when administered on an external infusion pump, please refer to the specific policy: MA05.053 Implantable and External Infusion Pumps.
  • Administration of deferoxamine (J0895) for the treatment of chronic iron overload
  • Administration of chemotherapy for the treatment of primary hepatocellular carcinoma or colorectal cancer when the disease is unresectable or when the individual refuses surgical excision of the tumor
  • Administration of morphine (J2270) for the treatment of intractable pain caused by cancer
  • Administration of continuous subcutaneous insulin (J1817) to treat individuals with diabetes mellitus
  • Administration of other drugs when all of the following criteria are met:
    • Parenteral administration of the drug in the home setting is medically appropriate.
    • An infusion pump is necessary to safely administer the drug
    • Either of the following criteria is met:
      • The drug is administered by a prolonged infusion of at least 8 hours because of proven improved clinical efficacy, and the therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or infusions lasting less than 8 hours
      • The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) which does not require the individual to return to the physician's office prior to the beginning of each infusion, and systemic toxicity or adverse effects of the drug are unavoidable without infusing the drug at a strictly controlled rate (ie, as indicated in the Physicians' Desk Reference or the US Pharmacopeia Drug Information)
    • As determined by Medicare, these other drugs include:
      • Administration of the anticancer chemotherapy drugs cladribine (J9065), fluorouracil (J9190), cytarabine (J9100, bleomycin (J9040), floxuridine (J9200), doxorubicin (non-liposomal) (J9000), vincristine (J9370), or vinblastine (J9360) by continuous infusion over at least 8 hours when the regimen is proven or generally accepted to have significant advantages over intermittent administration regimens
      • Administration of narcotic analgesics (J1170, J3010, J7799) (except meperidine (J2175) in place of morphine (J2270) to an individual with intractable pain caused by cancer who has not responded to an adequate oral/transdermal therapeutic regimen and/or cannot tolerate oral/transdermal narcotic analgesics
      • Administration of the following antifungal or antiviral drugs: Acyclovir (J0133), foscarnet (J1455), amphotericin B (J0285, J0287, J0288, J0289), and ganciclovir (J1570)
      • Administration of subcutaneous immune globulin. (Please refer to the specific policy on Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
      • 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
      • Administration of epoprostenol (J1325) or treprostinil (J3285) for individuals with pulmonary hypertension (please refer to the specific policy, Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents)
      • Administration of Gallium nitrate (J1457) for the treatment of symptomatic cancer-related hypercalcemia
      • Administration of Ziconotide (J2278) for the management of severe chronic pain in individuals for whom intrathecal (IT or epidural) therapy is warranted and who are intolerant of or refractory to other treatments, such as systemic analgesics, adjunctive therapies, or IT morphine
      • Administration of pooled plasma derivative, subcutaneous immune globulin (J1559, J1561, J1569) for the treatment of documented primary immune deficiency disease (please refer to the specific policy on Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
      • Levodopa-Carbidopa enteral suspension (Duopa) (J7340) for the treatment of motor fluctuations in individuals with Parkinson’s disease (PD), who meet all of the following criteria:
        • The individual has been evaluated by a neurologist, who prescribes and manages treatment with the drug; and
        • Idiopathic PD based on the presence of bradykinesia and at least one other cardinal PD features (tremor, rigidity, postural instability); and
        • L-dopa responsive with clearly defined “On” periods; and
        • Persistent motor complications with disabling “Off” periods for a minimum of 3 hours/day, despite medical therapy with levodopa-carbidopa, and at least one other class of anti-PD therapy (i.e. catechol-o-methyltransferase (COMT) inhibitor or monoamine oxidase inhibitors (MAO-B) inhibitor).
      • Blinatumomab (J9039) for the treatment of adult individuals with the following:
        • Relapsed or refractory B-cell acute lymphoblastic leukemia (ALL), or
        • Minimal residual disease positive (MRD+) B-cell acute lymphoblastic leukemia (B-ALL)
          (please refer to the specific policies, Implantable and External Infusion Pumps and Blinatumomab [Blincyto®])


    Drug Code Narratives

    Code
    Description
    J0133
    Injection, acyclovir, 5 mg
    J0285
    Injection, amphotericin B, 50 mg
    J0287
    Injection, amphotericin B lipid complex, 10 mg
    J0288
    Injection, amphotericin B cholesteryl sulfate complex, 10 mg
    J0289
    Injection, amphotericin B liposome, 10 mg
    J0895
    Injection, deferoxamine mesylate, 500 mg
    J1170
    Injection, hydromorphone, up to 4 mg
    J1250
    Injection, dobutamine HCI, per 250 mg
    J1265
    Injection, dopamine HCl, 40 mg
    J1325
    Injection, epoprostenol, 0.5 mg
    J1455
    Injection, foscarnet sodium, per 1,000 mg
    J1457
    Injection, gallium nitrate, 1 mg
    J1559
    Injection, immune globulin (Hizentra), 100mg
    J1561
    Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg
    J1569
    Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg
    J1570
    Injection, ganciclovir sodium, 500 mg
    J1817
    Insulin for administration through DME (i.e., insulin pump) per 50 units
    J2175
    Injection, meperidine HCl, per 100 mg
    J2260
    Injection, milrinone lactate, 5 mg
    J2270
    Injection, morphine sulfate, up to 10 mg
    J2278
    Injection, ziconotide, 1 mcg
    J3010
    Injection, fentanyl citrate, 0.1 mg
    J3285
    Injection, treprostinil, 1 mg
    J7340
    Carbidopa 5mg/levodopa 20mg enteral suspension, 100 ml
    J7799
    NOC drugs, other than inhalation drugs, administered through DME
    J9000
    Injection, doxorubicin HCl, 10 mg
    J9039
    Injection, blinatumomab, 1 microgram
    J9040
    Injection, bleomycin sulfate, 15 units
    J9065
    Injection, cladribine, per 1 mg
    J9100
    Injection, cytarabine, 100 mg
    J9190
    Injection, fluorouracil, 500 mg
    J9200
    Injection, floxuridine, 500 mg
    J9360
    Injection, vinblastine sulfate, 1 mg
    J9370
    Vincristine sulfate, 1 mg


    Version Effective Date: 01/01/2020
    Version Issued Date: 12/31/2019
    Version Reissued Date: N/A

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