Notification



Notification Issue Date:



Claim Payment Policy


Title:Marijuana for Medical Use

Policy #:00.01.48c

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

Company benefit contracts indicate that in order for a drug to be eligible for reimbursement consideration the US Food and Drug Administration (FDA) must first issue final approval for the product to be marketed for a specific approved condition or diagnosis. To date, the FDA has not approved the use of marijuana for medical use; therefore, marijuana for medical use is considered a benefit contract exclusion and is not eligible for reimbursement consideration.

Although state mandates, such as the "New Jersey Compassionate Use Medical Marijuana Act" and the Pennsylvania "Medical Marijuana Act" recognize that marijuana use is not against the law when prescribed by a professional provider based on lack of FDA approval, such state mandates do not impact the Company's position and, therefore, medical use of marijuana is not eligible for reimbursement.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, medical use of marijuana is a benefit contract exclusion for all products of the Company.

Description

The US Food and Drug Administration (FDA) is responsible for the approval and marketing of drugs for medical use, including controlled substances.

For the purpose of this policy, the term marijuana refers to the dried leaves and flowers of Cannabis sativaplant, and any mixture or preparation thereof, and does not include FDA-approved drugs (e.g., dronabinol [Marinol™] or nabilone [Cesamet]) that may contain active ingredients that are present in marijuana.

Medical use of marijuana refers to the use of marijuana, including components of marijuana as a professional provider's recommended form of medicine or herbal therapy, often to treat individuals with chronic or terminal illnesses. Medical marijuana can be smoked, vaporized (heated until active ingredients are released), eaten (in the form of brownies, cookies, or candy), or taken as a liquid extract.

Some states have authorized the use of marijuana for medical treatment. In those states where its use for medical treatment is not prohibited, it is typically prescribed by a professional provider to control pain in chronic disease or cancer, to control nausea and vomiting related to cancer chemotherapy, to help increase appetite when weight loss is caused by chronic illness, and for management of headaches or pain caused by inflammation of the nerves. If a professional provider in a state where the use of medical marijuana has been authorized believes that the use of marijuana will be beneficial as a medical treatment, and the person for whom it is being prescribed is a legal resident of that same state, marijuana may be prescribed for certain such state-approved conditions. The person is given documentation that grants eligibility to participate in the medical marijuana program and is listed in a state directory as a person who is able to purchase marijuana with a professional provider's prescription from an authorized medical marijuana dispensary.
References


Company Benefit Contracts.

Harding A. Medical Marijuana. WebMD. Pain Management Health Center. [WebMD Web site.] 11/4/2013. Available at:
http://www.webmd.com/pain-management/features/medical-marijuana-uses. Accessed August 14, 2018.

National Institutes of Health (NIH). National Institute on Drug Abuse. Marijuana - Drug Facts. [NIH Web site].March 2016. Available at:
http://www.drugabuse.gov/publications/drugfacts/marijuana. Accessed August 14, 2018.

New Jersey Senate Bill 119, dated JANUARY 7, 2010. Available at: http://medicalmarijuana.procon.org/sourcefiles/NJS119.PDF. Accessed August 14, 2018.

Pennsylvania Senate Bill 3, dated JANUARY 26, 2015. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2015&sessInd=0&billBody=S&billTyp=B&billNbr=0003&pn=1690. Accessed August 14, 2018.

US Food and Drug Administration (FDA). U.S. Department of Health and Human Services. Researching the Potential Medical Benefits and Risk of Marijuana. [FDA web site]. 07/13/2016. Available at:
https://www.fda.gov/newsevents/testimony/ucm511057.htm. Accessed August 14, 2018.

US Food and Drug Administration (FDA). U.S. Department of Health and Human Services. FDA and Marijuana. [FDA website]. 02/09/2016. Available at:
http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421163.htm. Accessed August 14, 2018.

US Food and Drug Administration (FDA). U.S. Department of Health and Human Services. FDA and Marijuana: Questions and Answers. [FDA website]. 09/30/2015. Available at: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm. Accessed August 14, 2018.




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)

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 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)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Revisions to 00.01.48c
09/26/2018This policy has been reissued in accordance with the Company's annual review process.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 05/18/2016
Version Issued Date: 05/18/2016
Version Reissued Date: 09/26/2018

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.