Archive Article for Paclitaxel (e.g., Taxol®/Abraxane ™) - Related to LCD L25820 (A46758)

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 

A46758 

Article Type 

Article

Key Article 

Yes

Article Title

Paclitaxel (e.g., Taxol®/Abraxane ™) - 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 

03/01/2008

 

Article Revision Effective Date 

08/18/2008

 

Article Text 

This article defines coding and coverage for paclitaxel 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:
Paclitaxel is an intravenous antineoplastic agent that inhibits the replication of cancer cells.

Indications:
Paclitaxel is covered for the treatment of:

  • Carcinoma of the cervix uteri
  • Ovarian cancer
  • Kaposi's sarcoma
  • Endometrial carcinoma
  • Breast cancer
  • Small cell carcinoma of the lung
  • Non small cell carcinoma of the lung
  • Angiosarcoma
  • Cancer of unknown origin
  • Cancer of the bladder
  • Cancer of the esophagus
  • Carcinoma of fallopian tube, in combination with carboplatin or cisplatin
  • Cervical cancer
  • Gastric cancer
  • Head and neck cancer
  • Malignant lymphoma
  • Malignant tumor of nasopharynx
  • Malignant tumor of peritoneum, of ovarian origin; in combination with carboplatin or cisplatin
  • Multiple myeloma
  • Oligodendroglioma of brain


Indications expanded by this Article:

  • Hormone refractory prostate carcinoma
  • Carcinoma of the renal pelvis and ureter
  • Testicular, cancer
  • Rhabdomyosarcoma
  • Leiomyosarcoma


Albumin-bound paclitaxel is covered for the treatment of:

  • Metastatic breast cancer
  • Anal cancer
  • Head and neck cancer


Documentation Requirements:
For any claims submitted for albumin-bound paclitaxel, documentation should be included in the patient’s medical record showing prior therapy included an anthracycline unless clinically contraindicated and available to the Contractor upon request.

Coding Guildelines:

For claims submitted to the carrier:

Paclitixal 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 

 

J9264

INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG

J9265

PACLITAXEL, 30 MG

 

ICD-9 Codes that are Covered 

 

The following ICD-9-CM codes are payable indications for albumin-bound paclitaxel only.

174.0

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1

MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2

MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3

MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4

MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5

MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6

MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST

174.9

MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

175.0

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9

MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

196.0

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK

196.1

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES

196.3

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB

197.0

SECONDARY MALIGNANT NEOPLASM OF LUNG

197.7

MALIGNANT NEOPLASM OF LIVER SECONDARY

198.3

SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.4

SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM

198.5

SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

198.89

SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

V10.3

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST



The following ICD-9-CM codes are payable indications for paclitaxel only.

140.0

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER

140.1

MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER

140.3

MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT

140.4

MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT

140.5

MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT

140.6

MALIGNANT NEOPLASM OF COMMISSURE OF LIP

140.8

MALIGNANT NEOPLASM OF OTHER SITES OF LIP

140.9

MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER

141.0

MALIGNANT NEOPLASM OF BASE OF TONGUE

141.1

MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE

141.2

MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE

141.3

MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE

141.4

MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED

141.5

MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE

141.6

MALIGNANT NEOPLASM OF LINGUAL TONSIL

141.8

MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE

141.9

MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

142.0

MALIGNANT NEOPLASM OF PAROTID GLAND

142.1

MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND

142.2

MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

142.8

MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS

142.9

MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED

143.0

MALIGNANT NEOPLASM OF UPPER GUM

143.1

MALIGNANT NEOPLASM OF LOWER GUM

143.8

MALIGNANT NEOPLASM OF OTHER SITES OF GUM

143.9

MALIGNANT NEOPLASM OF GUM UNSPECIFIED

144.0

MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH

144.1

MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH