NGS VA Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (A47777)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00453

Contractor Type

Article Information

Article ID Number

A47777

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

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

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

Virginia

Secondary Geographic Jurisdiction

Virginia

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	Adalimumab (Injection Adalimumab, 20mg)	01/01/2003	N/A	Apparent on its face; 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)	Alprostadil injection	01/01/2003	N/A	Apparent on its face; intracavernosal injection by patient on an as-needed basis up to three times per week.
J3490	UNCLASSIFIED DRUGS	Anakinra	09/15/2003	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J0364	INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG	Apomorphine HCl (Apokyn®)	05/20/2004	N/A	Apparent on its face; subcutaneous injection for acute, intermittent treatment.
J3590	UNCLASSIFIED BIOLOGICS	Becaplermin (Regranex ® Gel)	04/27/2006	N/A	CR 5123: This product is usually self-administered by the patient.
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Calcitonin-salmon	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient daily or every other day for more than two weeks.
J0945	INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG	Brompheniramine maleate, injection, per 10 mg	06/13/2008	N/A	Apparent on its face; injectable form rarely medically reasonable and necessary when oral form not tolerated.
J3490	UNCLASSIFIED DRUGS	Efalizumab (Raptiva®)	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Enfuvirtide (Fuzeon®)	10/21/2005	N/A	Apparent on its face; subcutaneous injection BID 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)	Etanercept	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient twice weekly for more than two weeks.
J3490	UNCLASSIFIED DRUGS	Exanantide (Byetta®)	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Glatiramer acetate (Copaxone®)	09/15/2003	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Histrelin acetate	05/19/2006	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J1562	INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG	Immune globulin, subcutaneous (Vivaglobin®)	02/14/2007	N/A	Apparent on its face; subcutaneous injection weekly for a prolonged period of time.
90284	IMMUNE GLOBULIN (SCIG), HUMAN, FOR USE IN SUBCUTANEOUS INFUSIONS, 100 MG, EACH	Immune globulin (SCIg), subcutaneous (e.g., Vivaglobin®)	02/18/2008	N/A	Apparent on its face; subcutaneous injection weekly for a prolonged period of time.
J1815	INJECTION, INSULIN, PER 5 UNITS	Insulin	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Insulin	05/25/2003	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Interferon alfacon-1	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently for a prolonged period of time.
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Interferon alfa-2a	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient three times per week for more than two weeks.
Q3026	INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE	Interferon beta – 1a	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently 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)	Interferon-beta - 1b	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient every other day for more than two weeks.
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Interferon gamma-1B	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently for a prolonged period of time.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Leuprolide acetate (Lupron®)	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient for more than two weeks.
J2170	INJECTION, MECASERMIN, 1 MG	Mecasermin	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Octreotide (short-acting subcutaneous dose)	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently for a prolonged period of time.
J3490	UNCLASSIFIED DRUGS	Olanzapine	07/19/2005	N/A	Utilization data indicates only intramuscular usage for scheduled administration when oral administration should be used.
J3490	UNCLASSIFIED DRUGS	Pegylated interferon alfa-2a	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently for a prolonged period of time
J3490	UNCLASSIFIED DRUGS	Pegylated interferon alfa-2b (PEG-Intron®)	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently for a prolonged period of time.
J3490	UNCLASSIFIED DRUGS	Pervisomant (Somavert®)	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J3490	UNCLASSIFIED DRUGS	Pramlintide (Symlin®)	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Sermorelin acetate	05/25/2007	N/A	Apparent on its face; subcutaneous administration by the patient daily for more than two weeks.
J2940	INJECTION, SOMATREM, 1 MG	Somatrem	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient several times each week for more than two weeks.
J2941	INJECTION, SOMATROPIN, 1 MG	Somatropin (human growth hormone)	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient several times each 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)	Sumatriptan succinate	01/01/2003	N/A	Apparent on its face; subcutaneous administration by the patient more than once daily on an as-needed basis for more than two weeks.
J3110	INJECTION, TERIPARATIDE, 10 MCG	Teriparatide	05/25/2003	N/A	Apparent on its face; subcutaneous injection frequently for a prolonged period of time.
J3355	INJECTION, UROFOLLITROPIN, 75 IU	Urofollitropin	05/19/2006	N/A	Apparent on its face; subcutaneous injection daily for a prolonged period of time.
J3490	UNCLASSIFIED DRUGS	Warfarin sodium (Coumadin®)	02/16/2005	N/A	Apparent on its face; rarely given IV when oral not tolerated.

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 2008: This article replaces - A2372 - Self-Administered Drug Exclusion - Medical Policy Article. The updated article has added HCPCS code J0945 (Brompheniramine maleate) to match the carrier.

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