NGS OH Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (R13) (A2313)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00332

Contractor Type

Article Information

Article ID Number

A2313

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (R13)

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

Ohio

Secondary Geographic Jurisdiction

Ohio

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	04/15/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
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	12/01/2002	N/A	Intracavernosal injection by patient on an as needed basis up to 3 times per week
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcimar, Miacalcin	12/01/2002	N/A	Subcutaneous injection by patient every day or every other day for a prolonged period of time
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	12/01/2002	N/A	Subcutaneous injection by patient twice per week for a prolonged period of time.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	09/15/2003	N/A	Subcutaneous injection by patient every day for a prolonged period of time
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog, Regular, NPH, Lente, Ultralente	12/01/2002	N/A	Subcutaneous injection by patient every day for a prolonged period of time
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog, Regular, NPH, Lente, Ultralente	12/01/2002	N/A	Subcutaneous injection by patient every day for a prolonged period of time
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	12/01/2002	N/A	Subcutaneous injection by patient every other day for a prolonged period of time
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Sandostatin	05/01/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
J2940	INJECTION, SOMATREM, 1 MG	Protopin, Genotropin, Humatrope, Norditropin, Nutropin, Saizen, Serostim	12/01/2002	N/A	Subcutaneous injection by patient several times per week for a prolonged period of time
J2941	INJECTION, SOMATROPIN, 1 MG	Protopin, Genotropin, Humatrope, Norditropin, Nutropin, Saizen, Serostim	12/01/2002	N/A	Subcutaneous injection by patient several times per week for a prolonged period of time
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	12/01/2002	N/A	Subcutaneous injection by patient at onset of symptoms up to two times in a 24 hour period on an as needed basis
J3110	INJECTION, TERIPARATIDE, 10 MCG	Forteo	04/15/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
J3490	UNCLASSIFIED DRUGS	Pegasys	04/15/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
J3490	UNCLASSIFIED DRUGS	PEG-Intron	05/01/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Enfuviritide, Fuzeon	12/16/2004	N/A	Subcutaneous injection daily for a prolonged period of time
J3490	UNCLASSIFIED DRUGS	Kinere	09/15/2003	N/A	Subcutaneous injection by patient every day for a prolonged period of time
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	05/01/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	04/15/2003	N/A	Subcutaneous injection frequently for a prolonged period of time
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron	12/01/2002	N/A	Dose form for daily subcutaneous injection by patient for a prolonged period of time
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	12/15/2006	N/A	Subcutaneous injection daily for a prolonged period of time.
J3355	INJECTION, UROFOLLITROPIN, 75 IU	Bravelle	12/15/2006	N/A	Subcutaneous injection daily for a prolonged period of time.
J2170	INJECTION, MECASERMIN, 1 MG	Iplex, Increlex	10/15/2007	N/A	Dose form for more than once daily subcutaneous injection by patient for more than two weeks.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Geref	10/15/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3490	UNCLASSIFIED DRUGS	Exenatide, Byetta	10/15/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3490	UNCLASSIFIED DRUGS	Pramlintide acetate, Symlin®	10/15/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3590	UNCLASSIFIED BIOLOGICS	Efalizumab, Raptiva	10/15/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3590	UNCLASSIFIED BIOLOGICS	Pegvisomant, Somavert®	10/15/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 2008 (R13): 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 September 2007 (R12): Article revised to include HCPCS code J2170 (Mecasermin), Q0515 (Semorelin), J3490 (Exenatide), J3490 (Pramlintide) and J3590 (Efalizumab) to match the carrier. The effective date for the above mentioned codes is 10/15/2007. Article published February 2007 (R11): Article revised to replace HCPCS code for Enfuvirtide Fuzeon from J3490 to J1324, due to the annual 2007 HCPCS update, with no change in effective date. HCPCS code Q3026 (Rebif) is deleted due to code status "I", not payable by Medicare. HCPCS code J3490, Sandostatin (unclassified drugs) also deleted due to duplicate entry. As part of our new corporate identity implementation, the contractor name has also been changed to National Government Services (formerly AdminaStar Federal) beginning with this version of the Article. Article published November 2006 (R10): Article revised to include Supprelin (J1675)and Bravelle (J3355), brand-name drugs, to the list to match the carrier. The two additional codes are effective 12/15/2006. Article published January 2006 (R9): Article revised to exclude Leuprolide acetate injection, brand-name drug, 1 mg (C9430) from the list due to the 2006 HCPCS changes. Also, J2352 was removed from the list. Article published February 2005 (R8): The list of excluded drugs is updated: The code for teriparatide is changed from J3490 to J3110; the code for adalimumab is changed from J3490 to J0135. Both changes are effective 01/01/2005. 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.

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