Drugs and Biologicals, Coverage for, Label and Off-Label Uses - L25820

R3 (effective date April 1, 2008): Source of Revision – Internal: The following template paragraph has been removed from the “Other Comments” section: A claim that does not fulfill the coverage requirements described above may be given individual consideration based on review of all pertinent medical information during the appeals process. The following article has been added: Intravenous Immune Globulin (IVIG) (A47381). No comment and notice periods required and none given.

Bevacizumab (e.g., Avastin ™) - Related to LCD L25820 (A46095)

Article published April 2008: Source of revision – internal/external: The article text paragraph has been revised for clarity and to correct the spelling of pharmacopoeia. The chemotherapy “Indications” has also been revised for clarity. The coding guidelines have been separated into “Carrier and Intermediary” guidelines and the language has been revised. Site modifier information has been added for CPT code 67028 and HCPCS codes C9399 and J3490. Under the guidelines for “Age-Related Macular Degeneration” in the “Carrier” guideline section, the pharmacy name requirement has been removed from the invoice guideline. The acronym “NDC” has been corrected as well as correcting the spelling of bevacizumab in various places. Bill types have been added.

Gemcitabine Hydrochloride (e.g., Gemzar®) – Related to LCD L25820 (A46103)

Article published April 2008: Source of revision – internal/external: The article text paragraph has been revised for clarity and to correct the spelling of pharmacopoeia. Revised “Indications” to remove label and off-label verbiage. Places of service have been revised. Bill types have been added. Diagnosis for malignant neoplasm of intrahepatic bile ducts (ICD-9-CM code 155.1) has been added based on an external comment. ICD-9CM code V10.07 has also been added.

Pamidronate Disodium for Injection (e.g., Aredia®) - Related to LCD L25820 (A46738)

Article published April 2008: Source of revision – internal/external: headings have been added to the ICD-9-CM sections for clarity. The following ICD-9-CM codes have been added to the ICD-9-CM section for osteolytic bone metastasis of breast cancer which were inadvertently missed: 162.0-162.9, 185, V10.11, V10.12, and V10.46.

Temsirolimus (Torisel ™) – Related to LCD L25820 (A46089)

Article published April 2008: Source of revision – internal/external – HCPCS code C9239 has been added effective for dates of service on or after January 1, 2008. This code was inadvertently missed during the annual HCPCS update. Template language has been revised in the “Article Text” paragraph. Bill types have been added. “Carrier” and “Intermediary” guidelines have been separated and language clarified. Places of service have been added to the “Carrier” guidelines. Corrected spelling for acronym “NDC.”