NGS CA Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (A47778)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00454

Contractor Type

Article Information

Article ID Number

A47778

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article

Primary Geographic Jurisdiction

California - Entire State

Secondary Geographic Jurisdiction

California

Original Article Effective Date

07/01/2008

Article Revision Effective Date

07/01/2008

Article Text

The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see "Process for Determining Self-Administered Drug Exclusions – Medical Policy Article"). The column, "Brand Names," provides one or more examples but not all. Information about drugs not separately reimbursed or not covered for reasons other than "usually self-administered," is found in other carrier and fiscal intermediary publications and sites.

In the interest of consistent Medicare coverage, the National Government Services fiscal intermediary will follow the coverage decision for self-administered drugs as determined by the carrier in each respective state. HCPCS codes for the same drugs that apply only to providers that bill the fiscal intermediary (e.g., HCPCS codes used for drugs billable under the Outpatient Prospective Payment System [OPPS]) are included when applicable.

Coverage Topic

Outpatient Hospital Services
Prescription Drugs

Coding Information

No Coding Information has been entered in this section of the article.

Coding Table Information

CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Comments
J0135	INJECTION, ADALIMUMAB, 20 MG	Humira	01/01/2005	N/A	Rationale for Determination Subcutaneous injection once every other week for more than two weeks. Can be administered every week. Prior to 1/1/2005, use J3490.
J0270	INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Caverjet, Edex	03/15/2003	N/A	Rationale for Determination Apparent on its face.
J0364	INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG	Apokyn	01/01/2007	N/A	Rationale for Determination For subcutaneous administration only.
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcimar, Miacalcin	03/15/2003	N/A	Rationale for Determination Subcutaneous injection daily for more than two weeks.
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Fuzeon	01/01/2007	N/A	New J code for 2007 Rationale for Determination Subcutaneous injection twice daily. Prior to 2007 use J3490.
J1438	INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Enbrel	03/15/2003	N/A	Rationale for Determination Subcutaneous injection daily for more than two weeks.
J1562	INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG	Vivaglobin	01/01/2007	N/A	Rationale for Determination Apparent on its face.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	01/01/2004	N/A	Rationale for Determination Subcutaneous injection daily.
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	01/01/2006	N/A	Rationale for Determination Subcutaneous injection daily.
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog, Regular, NPH, Lente, Ultralente		N/A	Rationale for Determination Subcutaneous injection daily for more than two weeks.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog	01/01/2003	N/A	Rationale for Determination Subcutaneous injection daily for more than two weeks. Replaced K0548. Humalog also identified under code J1815.
J1830	INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Betaseron	03/15/2003	N/A	Rationale for Determination Subcutaneous injection every other day for more than two weeks.
J2170	INJECTION, MECASERMIN, 1 MG	Increlex	01/01/2007	N/A	Rationale for Determination Subcutaneous injection twice daily.
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Sandostatin	01/01/2007	N/A	Rationale for Determination Subcutaneous injection is the usual route of administration.
J2440	INJECTION, PAPAVERINE HCL, UP TO 60 MG		03/15/2003	N/A	Rationale for Determination Apparent on its face.
J2940	INJECTION, SOMATREM, 1 MG	Protopin	03/15/2003	N/A	Rationale for Determination Subcutaneous injection several times per week for more than two weeks.
J2941	INJECTION, SOMATROPIN, 1 MG	Gentropin, Humatrope, Norditropin, Nutropin, Saizen, Serostim	03/15/2003	N/A	Rationale for Determination Subcutaneous injection several times per week for more than two weeks.
J3030	INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Imitrex	03/15/2003	N/A	Rationale for Determination Apparent on its face.
J3110	INJECTION, TERIPARATIDE, 10 MCG	Forteo	01/01/2005	N/A	Rationale for Determination Subcutaneous injection daily for more than two weeks. Prior to 2005, J3490.
J3355	INJECTION, UROFOLLITROPIN, 75 IU	Fertinex, Metrodin	01/01/2006	N/A	Rationale for Determination Subcutaneous injection or Intramuscular injection once a day for seven or more days.
J3490	UNCLASSIFIED DRUGS	Peginterferon Alfa 2-b, PEG-Intron, Pegylated Interferon Alfa 2-b	03/15/2003	N/A	Rationale for Determination Subcutaneous injection once per week for more than two weeks.
J3490	UNCLASSIFIED DRUGS	Byetta (Exenatide)	01/01/2007	N/A	Rationale for Determination Subcutaneous injection twice a day within 60 minutes before the morning and evening meals.
J3490	UNCLASSIFIED DRUGS	Kineret (Anakinra)	01/01/2007	N/A	Rationale for Determination Subcutaneous injection daily.
J3490	UNCLASSIFIED DRUGS	Pegasys (Peginterferon Alfa-2a)	01/01/2007	N/A	Rationale for Determination Subcutaneous injection once per week from 24-48 weeks.
J3490	UNCLASSIFIED DRUGS	Symlin (Pramlintide acetate)	01/01/2007	N/A	Rationale for Determination Subcutaneous injection administered immediately prior to each major meal.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	03/15/2003	N/A	Rationale for Determination Subcutaneous injection thrice weekly for more than two weeks.
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Roferon-A	03/15/2003	N/A	Rationale for Determination Subcutaneous injection thrice weekly for more than two weeks. Data submitted does not show that more than 50% of Medicare patients do not usually self-inject.
J9215	INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU	Alferon N	03/15/2003	N/A	Rationale for Determination Subcutaneous injection twice a week for more than two weeks.
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	03/15/2003	N/A	Rationale for Determination Subcutaneous injection thrice a week for more than two weeks.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron	03/15/2003	N/A	Rationale for Determination Dose form for subcutaneous injection daily for more than two weeks.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Geref	01/01/2006	N/A	Rationale for Determination Subcutaneous injection once daily for greater than three weeks.

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 2008: This article replaces - A2372 - Self-Administered Drug Exclusion - Medical Policy Article.

Related Documents
Article(s) A47521 - Process for Determining Self-Administered Drug Exclusions – Medical Policy Article