NGS IN (Carrier) Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (formerly Self-Administered Drug (SAD) Exclusion List ) (A906)

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (formerly Self-Administered Drug (SAD) Exclusion List ) (A906)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00630

Contractor Type

Carrier

Article Information

Article ID Number

A906

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (formerly Self-Administered Drug (SAD) Exclusion List )

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

Indiana

Original Article Effective Date

02/01/2003

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

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)	Caverjet®, 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.
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Fuzeon	05/16/2007	N/A	Non-acute subcutaneous injection by patient, twice daily.
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 subcutaneous (SC) injection by patient, usually twice a week.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	05/16/2007	N/A	Self-administration; subcutaneous 20 mg/day.
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	05/16/2007	N/A	Non-acute subcutaneous administration, usually once daily by patient.
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog®, Humulin® R, Humalin® 50/50, Lente® Iletin® II, Novolin®	03/15/2003	N/A	Non-acute subcutaneous (SC) injection by patient every day.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog, Humulin, Iletin etc.	05/16/2007	N/A	Non-acute chronic filling of pump by patient.
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 subcutaneous(SC)injection by patient, usually every other day.
J2170	INJECTION, MECASERMIN, 1 MG	Increlex	05/16/2007	N/A	Non-acute subcutaneous injection, twice daily by patient.
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®,S Saizen®, Serostim®	03/15/2003	N/A	Non-acute subcutaneous (SC) injection by patient, several times a week.
J2941	INJECTION, SOMATROPIN, 1 MG	Protropin® Genotropin® Humatrope® Norditropin® Nutropin®	03/15/2003	N/A	Non-acute subcutaneous (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	Subcutaneous (SC) injection by patient at onset of symptoms (up to two times in a 24 hour period).
J3110	INJECTION, TERIPARATIDE, 10 MCG	Forteo®	10/15/2006	N/A	Non-acute, subcutaneous (SC) injection into thigh or abdomen (lower stomach area) once a day by patient using multidose prefilled delivery device (FORTEO pen - contains 28 daily doses).
J3490	UNCLASSIFIED DRUGS	Byetta (exenatide)	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 (pramlintide acetate)	08/15/2005	N/A	Non-acute subcutaneous (SC) injection by patient, immediately prior to major meals.
J3590	UNCLASSIFIED BIOLOGICS	Kineret	05/16/2007	N/A	Non-acute subcutaneous (SC) injection by patient, every day.
J3590	UNCLASSIFIED BIOLOGICS	Peg-Intron	05/16/2007	N/A	Subcutaneous weekly administration for one year by patient.
J3590	UNCLASSIFIED BIOLOGICS	Pegasys	05/16/2007	N/A	Subcutaneous weekly administration for 48 weeks by patient.
J3590	UNCLASSIFIED BIOLOGICS	Raptiva	05/16/2007	N/A	Non-acute subcutaneous weekly injection by patient.
J3590	UNCLASSIFIED BIOLOGICS	Somavert	05/16/2007	N/A	Non-acute subcutaneous injection daily, by patient.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	05/16/2007	N/A	Subcutaneous administration three times per week for 24-48 weeks, by patient.
J9213	INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS	Roferon A	05/16/2007	N/A	Hepatitis C: Sub-cutaneous administration three times per week for 12 months by patient. Hairy cell leukemia: Sub-cutaneous administration daily for 16 - 24 weeks and three times per week by patient. CML: Sub-cutaneous daily
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	05/16/2007	N/A	Non-acute subcutaneous administration usually three times per week by patient.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron®	03/15/2003	N/A	Non-acute, usually daily subcutaneous (SC) injection by patient. Corrected on 2/11/2003 from “Effective Date: March 15, 2003,” to "Effective Date: Non-covered prior to and after March 15, 2003.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	Geref	05/16/2007	N/A	Non-acute subcutaneous daily administration by patient.

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published 07/01/2008 The article text paragraph has been revised to remove information that can be found in: " Self-Administered Drug (SAD) Exclusion List – Medical Policy Article." Additional "brand" names added to some drugs. As part of the on going consolidation process throughout National Government Services the title has also been revised. There was no change made to the list of drugs. Article published 04/01/2007: The following drugs were added to the SAD list with an effective date of 05/16/2007: Fuzeon (J1324 – Injection, enfuvirtide, 1 mg); Copaxone (J1595 – Injection, glatiramer acetate, 20 mg); Somavert (J3590 – Unclassified biologics); Supprelin (J1675 – Injection, histrelin acetate, 10 micrograms); Humalog, Humulin, Ilentin etc. (J1817 – Insulin for administration through DME (i.e., insulin pump) per 50 units; Increlex (J2170 – injection, mecasermin, 1 mg); Raptiva (J3590 – unclassified biologics); Pegasys (J3590 – unclassified biologics); Peg-Intron (J3590 – unclassified biologics); Infergen (J9212 – Injection, interferon alfacon-1, recombinant, 1 mcg); Roferon A (J9213 – Interferon alpha 2-A); Actimmune (J9216 – Interferon, gamma 1-B, 3 million units); and Geref (Q0515 – Injection, sermorelin acetate, 1 microgram). Kineret was changed from HCPCS code J3490 (unclassified drugs) to J3590 (unclassified biologics) with an effective date of 05/16/2007. Article published 08/30/2006: Forteo (J3110 - Injection, teriparatide, 10 mcg) was added to the SAD list with an effective date of 10/15/2006. Article published 08/01/2005: Humira (J0135 – Injection, adalimumab, 20 mg) and Kineret (J3490 unclassified drugs) were added to SAD list with an effective date of September 15, 2005 Article published 07/01/2005: Sandostatin (J2354 – Injection octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg); Byetta (J3490 – Unclassified drugs); and Symlin (J3490 – unclassified drugs) were added to SAD list with an effective date of August 15, 2005.

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