Archive Article for Etoposide (Etopophos®, Toposar®, Vepesid®, VP-16) – Related to LCD L25820 (A47586)

Contractor Information

Contractor Name 

National Government Services, Inc.  

Contractor Number 

Number	Type	State(s)
00130	FI	IN
00131	FI	IL
00160	FI	KY
00180	FI	ME
00181	FI	MA
00270	FI	NH, VT
00308	FI	CT, DE, NY
00332	FI	OH
00450	FI	WI
00452	FI	MI
00453	FI	VA, WV
00630	Carrier	IN
00660	Carrier	KY
00805	Carrier	NJ
13101	MAC	CT – Part A
13102	MAC	CT – Part B
13201	MAC	NY – Part A
13202	MAC	NY – Part B
13282	MAC	NY- Part B
13292	MAC	NY – Part B

Contractor Type 

Carrier

Fiscal Intermediary

MAC – Part A

MAC – Part B

Article Information

Article ID Number 

A47586 

Article Type 

Article

Key Article 

Yes

Article Title 

Etoposide (Etopophos®, Toposar®, Vepesid®, VP-16) – Related to LCD L25820 

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 

Number	Type	State(s)
00130	FI	IN
00131	FI	IL
00160	FI	KY
00180	FI	ME
00181	FI	MA
00270	FI	NH, VT
00308	FI	CT, DE, NY
00332	FI	OH
00450	FI	WI
00452	FI	MI
00453	FI	VA, WV
00630	Carrier	IN
00660	Carrier	KY
00805	Carrier	NJ
13101	MAC	CT – Part A
13102	MAC	CT – Part B
13201	MAC	NY – Part A
13202	MAC	NY – Part B
13282	MAC	NY- Part B
13292	MAC	NY – Part B

Original Article Effective Date 

07/18/2008

Article Revision Effective Date 

08/18/2008

Article Text 

This article defines coding and coverage for etoposide including off-label indications. National Government Services Local Coverage Determination (LCD) “Coverage of Drugs and Biologicals for Label and Off-Label Uses” allows coverage for off-label indications only if the United States Pharmacopeia Drug Information (USP-DI), the American Hospital Formulary Services (AHFS) and/or Thomson Healthcare DrugPoints® (as described in the LCD) define such indications or if National Government Services has published an article or LCD expanding such coverage. Providers may request approval for additional off-label indications by submitting this request in writing with supporting medical literature. The aforementioned National Government Services LCD, which describes the requirements for such a request, can be accessed on our contractor Web site at www.NGSMedicare.com or on the Medicare Coverage Database at www.cms.hhs.gov/mcd.

Abstract:
Etoposide is an antineoplastic agent that interferes with cell division by interacting with DNA-topoisomerase II or free radical formation resulting in DNA strand breaks. It also affects the G2 portion of the mammalian cell cycle.

Indications:
Etoposide is FDA approved for the following indications:

• Management of refractory testicular tumors, in combination with other approved chemotherapeutic agents.
• In combination with other approved chemotherapeutic agents as first-line treatment in patients with small cell lung cancer.
• Gastric carcinoma
• Hepatoblastoma
• Neuroblastoma
• Non-small cell lung carcinoma
• Testicular cancer
• Malignant tumor of the thymus
• Osteosarcoma
• Ewing’s sarcoma
• Soft tissue sarcomas
• Cutaneous T cell lymphomas
• AIDS associated Kaposi’s sarcoma
• Endometrial carcinoma
• Ovarian germ cell tumors
• Wilms’ Tumor
• Retinoblastoma
• Adrenocortical carcinoma
• Acute lymphocytic leukemia
• Chronic myelocytic leukemia
• Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma
• Multiple myeloma
• Primary brain tumor
• Gestational trophoblastic tumor
• Cancer of Unknown Primary site (CUPs)
• Myelodysplastic syndromes (MDS)
• Bone marrow transplant
• Glioblastoma multiforme of brain
• Liver carcinoma
• Malignant mesothelioma
• Ovarian cancer
• Rhabdomyosarcoma

Indications Expanded by this Article

• Primary peritoneal carcinoma
• Fallopian tube carcinoma
• Breast carcinoma
• Bladder carcinoma
• Acute nonlymphocytic leukemia
• Trophoblastic neoplasm

Coding Guidelines:

For claims submitted to the carrier:

Carboplatin should be billed using chemotherapy administration codes and is payable in the following places of service: office (11), skilled nursing home for patients in a Part A stay (31) [if the drug is supplied by the facility, no claims for the drug should be submitted to the Part B carrier.], nursing facility for patients not in a Part A stay (32) and independent clinic (49) only when supplied as an “incident to” service by the physician.

Coverage Topic 

Chemotherapy (Inpatient)
Chemotherapy (Outpatient)
Prescription Drugs

Coding Information

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

11x	Hospital-inpatient (including Part A)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

CPT/HCPCS Codes 

J9181	ETOPOSIDE, 10 MG
J9182	ETOPOSIDE, 100 MG

ICD-9 Codes that are Covered 

151.0 - 151.9	MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
155.0	MALIGNANT NEOPLASM OF LIVER PRIMARY
155.2	MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY
158.8	MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
158.9	MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
160.0 - 160.9	MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED
162.0 - 162.9	MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED
164.0	MALIGNANT NEOPLASM OF THYMUS
164.8	MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM
170.0 - 170.9	MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED
171.0 - 171.9	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED
173.0 - 173.9	OTHER MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER MALIGNANT NEOPLASM OF SKIN SITE UNSPECIFIED
174.0 - 174.9	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
175.0 - 175.9	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
176.0 - 176.9	KAPOSI'S SARCOMA SKIN - KAPOSI'S SARCOMA UNSPECIFIED SITE
181	MALIGNANT NEOPLASM OF PLACENTA
182.0 - 182.8	MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS
183.0	MALIGNANT NEOPLASM OF OVARY
183.2	MALIGNANT NEOPLASM OF FALLOPIAN TUBE
183.9	MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE
186.0 - 186.9	MALIGNANT NEOPLASM OF UNDESCENDED TESTIS - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS
188.0 - 188.9	MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
189.0	MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
190.5	MALIGNANT NEOPLASM OF RETINA
191.0 - 191.9	MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
194.0 - 194.9	MALIGNANT NEOPLASM OF ADRENAL GLAND - MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE UNSPECIFIED
197.6	SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM
198.5	SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
199.0 - 199.1	DISSEMINATED MALIGNANT NEOPLASM - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
200.00 - 200.88	RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.00 - 201.98	HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 - 202.98	NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00 - 203.01	MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA IN REMISSION
204.00 - 204.01	ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - LYMPHOID LEUKEMIA ACUTE IN REMISSION
205.00 - 205.01	ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MYELOID LEUKEMIA ACUTE IN REMISSION
205.10 - 205.11	CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MYELOID LEUKEMIA CHRONIC IN REMISSION
206.00 - 206.01	ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MONOCYTIC LEUKEMIA ACUTE IN REMISSION
207.00 - 207.01	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION
236.1	NEOPLASM OF UNCERTAIN BEHAVIOR OF PLACENTA
238.71 - 238.79	ESSENTIAL THROMBOCYTHEMIA - OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES

Other Information

Other Comments 

Sources of Information

American Society of Health-System Pharmacists, Inc. AHFS Drug Information®. Bethesda, MD: 2007.

First Coast Policy #L25091, Etoposide (Etopophos®, Toposar®, Vepesid®, VP-16)

Thomson Healthcare DrugPoints® at http://www.thomsonhc.com/home/dispatch

United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.

08/18/2008 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00454 was removed from this LCD as the claims processing for American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands was transitioned to Palmetto GBA, the Part A/Part B MAC contractor in these states.

08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update.

Revision History Explanation