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Sources
of Information
American Society of Health-System Pharmacists, Inc.
AHFS Drug Information®. Bethesda,
MD: 2007.
Clinical Pharmacology
NCCN Drugs and Biologics Compendium accessed at: http://www.nccn.org/
Thomson Micromedix DrugDex®
accessed at:
http://www.thomsonhc.com/home/dispatch
Thomson
Healthcare DrugPoints® at
http://www.thomsonhc.com/home/dispatch
U.S. Food and Drug Administration label approved 05/18/2004 accessed on
line at
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ on
11/19/2007.
United States Pharmacopoeia (USP), Volume I; Drug Information for the
Health Care Professional, 2007.
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Revision History Explanation
Article published January 2009: Source
of revision – Internal - The “Article Text” and “Sources of Information”
have been revised to include compendia recognized by CMS based on Change
Request 6191 (Compendia as Authoritative Sources for Use in the
Determination of a Medically Accepted Indication of Drugs and Biologicals Used Off-Label in an Anti-Cancer
Chemotherapeutic Regimen, effective 11/25/2008). This article has been
reviewed using all listed compendia and is up to date. Minor changes were made to reflect current template language.
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Article published
October 2008: Source of revision – Internal (annual ICD-9-CM code updates for 2009). The “ICD-9-CM Codes That
Support Medical Necessity” section of the article is modified as follows:
the description for ICD-9-CM codes 205.00, 205.10 and 205.20 has been
modified. ICD-9-CM codes 205.02, 205.12 and 205.22 have been added.
This revised article is effective for all National Government Services
jurisdictions on July 18, 2008 with these exceptions: for Connecticut –
Part B the article is effective on August 1, 2008; for Upstate New York –
Part B, the article is effective on September 1, 2008; and for New York and
Connecticut – Part A, the article is effective on November 14, 2008. For New York – Part A
(contract 00308), the content of this article is currently in effect but
the article will be transferred to the J-13 contract number 13201 on
November 14, 2008.
This article was revised to add the Jurisdiction 13 (J-13) MAC contractor
numbers and to retain the most clinically appropriate medical policy
information within the jurisdiction, including off-label indications and
approved indications from DrugPoints®.
The following indication has been added: acute myeloid leukemia. The
following ICD-9-CM codes have been added: 205.00, 205.01, 238.71, 238.74
and 238.76. Thomson Healthcare DrugPoints® has
been added to the “Article Text” paragraph and “Sources of Information”.
Bill type codes have been added. Places of service for
claims submitted to the carrier has been revised.
Article published December 2007:
Original version of article.
The original version of the corresponding LCD became effective on 12/01/2007.
08/18/2008 - In accordance with Section 911 of the Medicare Modernization
Act of 2003, fiscal intermediary number 00454 was removed from this article
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.
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11/14/2008
- In accordance with Section 911 of the Medicare Modernization Act of 2003,
fiscal intermediary number 00308 is removed from this article. Effective on
this date, claims processing for Delaware is performed by Highmark Medicare
Services, the Part A/Part B MAC contractor for this state, and the claims
processing for New York and Connecticut is performed by National Government
Services under the J-13 MAC contract; carrier number 00805 is removed, and
claims processing for New Jersey is performed by Highmark Medicare
Services, the Part A/Part B MAC contractor for this state.
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