NGS KY Self -Administered Drugs and Biologicals Excluded from Coverage

Article for Self -Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (R14) (A2312)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00160

Contractor Type

Article Information

Article ID Number

A2312

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self -Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (R14)

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Kentucky

Secondary Geographic Jurisdiction

Kentucky

Original Article Effective Date

10/01/2002

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, 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	09/15/2005	N/A	Non-acute subcutaneous (SC) injection by patient, weekly or every other week.
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)	Caverject®, Edex®	03/15/2003	N/A	Usually self-injected by patient on an “as-needed” basis
J0275	ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Muse®	03/15/2003	N/A	Suppository
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcimar®, Miacalcin®, Osteocalcin®, Salmonine®	03/15/2003	N/A	Non-acute subcutaneous (SC) injection by patient, daily or every other day
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	Non-acute, SC injection by patient, usually twice a week
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog®, Humulin® R, Humalin® 50/50, Lente® Iletin® II, Novolin® R	03/15/2003	N/A	Non-acute, SC injection by patient every day
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	Non-acute, SC injection by patient, usually every other day
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Sandostatin	08/15/2005	N/A	Usually self-administed injections two to four times daily, depending on the indication.
J2940	INJECTION, SOMATREM, 1 MG	Protropin®, Genotropin®, Humatrope®, Norditropin®, Nutropin®, Saizen®, Serostim®	03/15/2003	N/A	Non-acute, SC injection by patient several times a week
J2941	INJECTION, SOMATROPIN, 1 MG	Protropin® Genotropin® Humatrope® Norditropin® Nutropin®	03/15/2003	N/A	(Injection, somatropin, 1 mg),Non-acute, SC injection by patient several times a week
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	SC injection by patient at onset of symptoms (up to two times in a 24 hour period)
J3490	UNCLASSIFIED DRUGS	Byetta	08/15/2005	N/A	Non-acute, subcutaneous (SC) injection by patient within the 60-minute period before morning and evening meals.
J3490	UNCLASSIFIED DRUGS	Symlin	08/15/2005	N/A	Non-acute, subcutaneous (SC) injection, by patient immediately prior to major meals.
J3590	UNCLASSIFIED BIOLOGICS	Kineret	05/19/2007	N/A	Non-acute, subcutaneous (SC) injection by patient every day.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron®	03/15/2003	N/A	Non-acute, usually daily SC injection by patient
J3110	INJECTION, TERIPARATIDE, 10 MCG	FORTEO®	10/15/2006	N/A	Non-acute, subcutaneous (SC) injection by patient, once a day.
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Fuzeon	05/19/2007	N/A	Non-acute subcutaneous injection by patient, twice daily.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	05/19/2007	N/A	Self-administration; subcutaneous 20 mg/day.
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	05/19/2007	N/A	Non-acute subcutaneous administration, usually once daily by patient.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog, Humulin, Iletin etc.	05/19/2007	N/A	Non-acute chronic filling of pump by patient.
J2170	INJECTION, MECASERMIN, 1 MG	Increlex	05/19/2007	N/A	Non-acute subcutaneous injection, twice daily by patient.
J3590	UNCLASSIFIED BIOLOGICS	Peg-Intron	05/19/2007	N/A	Subcutaneous weekly administration for one year by patient.
J3590	UNCLASSIFIED BIOLOGICS	Pegasys	05/19/2007	N/A	Subcutaneous weekly administration for 48 weeks by patient.
J3590	UNCLASSIFIED BIOLOGICS	Raptiva	05/19/2007	N/A	Non-acute subcutaneous weekly injection by patient.
J3590	UNCLASSIFIED BIOLOGICS	Somavert	05/19/2007	N/A	Non-acute subcutaneous injection daily, by patient.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	05/19/2007	N/A	Subcutaneous administration three times per week for 24-48 weeks, by patient.
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Roferon A	05/19/2007	N/A	Hairy cell leukemia: Subcutaneous administration daily for 16 - 24 weeks and three times per week by patient.
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	05/19/2007	N/A	Non-acute subcutaneous administration usually three times per week by patient.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Geref	05/19/2007	N/A	Non-acute subcutaneous daily administration by patient.

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 2008 (R14): The article text paragraph has been revised to remove information that can be found in: "Process for Determining Self-Administered Drug Exclusions – Medical Policy Article." As part of the on going consolidation process throughout National Government Services the previous title "Medicare Payment for Drugs and Biologicals Furnished Incident to a Physician's Service" has also been revised. Article published April 2007 (R13): Article has been revised to add the following codes to match the carrier, all have an effective date of 5/19/2007. The additions are: (J1324) Fuzeon (Injection, enfuvirtide, 1 mg); (J1595) Copaxone (Injection, glatiramer acetate, 20 mg); (J3590) Somavert (Unclassified biologics); (J1675) Supprelin (Injection, histrelin acetate, 10 micrograms); (J1817) Humalog, Humulin, Ilentin etc. (Insulin for administration through DME [i.e., insulin pump] per 50 units;) (J2170) Increlex (injection, mecasermin, 1 mg); (J3590) Raptiva (unclassified biologics); (J3590) Pegasys (unclassified biologics); (J3590) Peg-Intron (unclassified biologics); (J9212) Infergen (Injection, interferon alfacon-1, recombinant, 1 mcg); (J9213) Roferon A (Interferon alpha 2-A); (J9216) Actimmune (Interferon, gamma 1-B, 3 million units); and (Q0515) Geref (Injection, sermorelin acetate, 1 microgram). Kineret was changed from HCPCS code J3490 (unclassified drugs) to J3590 (unclassified biologics) with an effective date of 05/19/2007. References to the legacy AdminaStar Federal FI are changed to National Government Services. Article published September 2006 (R12): Article revised to include FORTEO® brand-name drug, 10 mcg (J3110) to the list effective October 15, 2006 to match the carrier. Article published January 2006 (R11): Article revised to exclude Leuprolide acetate injection, brand-name drug, 1 mg (C9430) from the list due to the 2006 HCPCS changes. Article published August 2005 (R10): Article revised to include Humira and Kineret on self-administered drug list exclusion effective September 15, 2005 to match the carrier. Article published July 2005 (R9): Article revised to include Sandostatin (octreotide acetate); Byetta (exenatide injection); and Symlin (pramlintide acetate) on self-administered drug list exclusion effective August 15, 2005 to match the carrier. Article published April 2005 (R8): Correction to typographical error. HCPCS code J2941 was previously published but subsequently omitted in error and is restored to the list. Article published January 2005 (R7): Self-administered drug (SAD) article (A2310) with links to carrier and Medicare Articles Database Web sites is revised replacing information about linking to the carrier exclusion list with the Indiana carrier list of excluded codes. This list is augmented with OPPS HCPCS code C9430. Article published December 2004 (R6): Annual review. CMS references throughout the text have been updated to reflect the CMS Online Manual System. Carrier Web addresses are updated. Article published December 2003 (R5): Updated Palmetto GBA (Ohio carrier) Web address. Article published November 2003 (R4): Added Medicare Articles Database link and carrier contractor numbers. Added WPS navigating instructions. Article published May 2003 (R3): Updated carrier Web addresses. Article published February 2003 (R2): Updated carrier Web addresses. Article published October 2002 (R1): Added carrier Web instructions Article published October 2002: Original article published on ASF Web site.

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