Article for Bortezomib (e.g., Velcade®) – Related to LCD L25820 (A47582)

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
00332	FI	OH
00450	FI	WI
00452	FI	MI
00453	FI	VA, WV
00630	Carrier	IN
00660	Carrier	KY
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 

A47582 

Article Type 

Article

Key Article 

Yes

Article Title 

Bortezomib (e.g., Velcade®) – Related to LCD L25820 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2008American 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
00332	FI	OH
00450	FI	WI
00452	FI	MI
00453	FI	VA, WV
00630	Carrier	IN
00660	Carrier	KY
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 

01/01/2009

Article Text 

This article defines coding and coverage for Bortezomib 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. Effective for dates of service on or after 11/25/2008, American Hospital Formulary Services (AHFS), Clinical Pharmacology, NCCN Drugs and Biologics Compendium and/or Thomson Micromedex DrugDex® compendium has replaced the USP-DI and Thomson Healthcare DrugsPoints®. 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:
Bortezomib (Velcade®) is an antineoplastic agent which inhibits the activity of the 26S proteasome. It exhibits cytotoxicity to various malignant cells, including myeloma and lymphoma cells. Brotezomib is given by intravenous injection.

Indications:
Bortezomib is approved for injection for the following:

• Treatment of patients with multiple myeloma who have received at least one prior therapy.
• Treatment of patients with mantle cell lymphoma who have received at least one prior therapy.
• Treatment of relapsed or refractory B-Cell Non-Hodgkin’s lymphoma specifically; follicular lymphoma.
• Multiple myeloma, newly diagnosed, in combination therapy
• Waldenstrom's macroglobulinemia

Indications expanded by this Article:

• Treatment of relapsed or refractory B-Cell Non-Hodgkin’s lymphoma specifically; follicular lymphoma

Documentation Requirements:
When a portion of the drug is discarded, the medical record must clearly show the amount administered and the amount wasted.

Coding Guidelines:

For claims submitted to the carrier or Part B MAC:

Bortezomib 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 

J9041

INJECTION, BORTEZOMIB, 0.1 MG

ICD-9 Codes that are Covered 

200.40	MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.41	MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.42	MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.43	MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.44	MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.45	MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.46	MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.47	MANTLE CELL LYMPHOMA, SPLEEN
200.48	MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.00	NODULAR LYMPHOMA UNSPECIFIED SITE
202.01	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.02	NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
202.03	NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.04	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.05	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.06	NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
202.07	NODULAR LYMPHOMA INVOLVING SPLEEN
202.08	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20	SEZARY'S DISEASE UNSPECIFIED SITE
202.21	SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.22	SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.23	SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.24	SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.25	SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.26	SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.27	SEZARY'S DISEASE INVOLVING SPLEEN
202.28	SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30	MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE
202.31	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.32	MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.33	MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.34	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.35	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.36	MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.37	MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN
202.38	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40	LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE
202.41	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.42	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.43	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.44	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
202.45	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.46	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.47	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN
202.48	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50	LETTERER-SIWE DISEASE UNSPECIFIED SITE
202.51	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.52	LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.53	LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.54	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.55	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.56	LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.57	LETTERER-SIWE DISEASE INVOLVING SPLEEN
202.58	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60	MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE
202.61	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.62	MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES
202.63	MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.64	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.65	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.66	MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES
202.67	MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN
202.68	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70	PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
202.71	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
202.72	PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
202.73	PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
202.74	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
202.75	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.76	PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
202.77	PERIPHERAL T CELL LYMPHOMA, SPLEEN
202.78	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80	OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
202.81	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.82	OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES
202.83	OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.84	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.85	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.86	OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES
202.87	OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN
202.88	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00	MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION