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

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 

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 2008 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

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 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. 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:

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 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
  • Germ cell tumor
  • Intracranial tumor, malignant
  • Nephroblastoma

 

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 or Part B MAC:

Etoposide 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 

HCPCS code J1982 has been deleted 12/31/2008.

J9181

INJECTION, ETOPOSIDE, 10 MG

 

ICD-9 Codes that are Covered 

 

151.0 - 151.6

MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8 - 151.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - 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 - 160.3

MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ETHMOIDAL SINUS

160.4

MALIGNANT NEOPLASM OF FRONTAL SINUS

160.5

MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 - 160.9

MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

162.0

MALIGNANT NEOPLASM OF TRACHEA

162.2 - 162.5

MALIGNANT NEOPLASM OF MAIN BRONCHUS - MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 - 162.9

MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG - 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

MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.2 - 171.9

MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER - 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 - 174.6

MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8 - 174.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST - 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

176.0 - 176.5

KAPOSI'S SARCOMA SKIN - KAPOSI'S SARCOMA LYMPH NODES

176.8 - 176.9

KAPOSI'S SARCOMA OTHER SPECIFIED SITES - KAPOSI'S SARCOMA UNSPECIFIED SITE

181

MALIGNANT NEOPLASM OF PLACENTA

182.0

MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS

182.1

MALIGNANT NEOPLASM OF ISTHMUS

182.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS

183.0

MALIGNANT NEOPLASM OF OVARY

183.2

MALIGNANT NEOPLASM OF FALLOPIAN TUBE

183.3

MALIGNANT NEOPLASM OF broad ligament

183.4

MALIGNANT NEOPLASM OF parametrium

183.5

MALIGNANT NEOPLASM OF round ligament

183.8

MALIGNANT NEOPLASM OF other specified sites of uterine adnexa

183.9

MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE

185

MALIGNANT NEOPLASM OF PROSTATE

186.0

MALIGNANT NEOPLASM OF UNDESCENDED TESTIS

186.9

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 - 194.1

MALIGNANT NEOPLASM OF ADRENAL GLAND - MALIGNANT NEOPLASM OF PARATHYROID GLAND

194.3 - 194.6

MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT - MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

194.8 - 194.9

MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES - 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

DISSEMINATED MALIGNANT NEOPLASM

199.1

OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE

200.00 - 200.08

RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.10 - 200.18

LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.20 - 200.28

BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.30 - 200.38

MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.40 - 200.48

MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.50 - 200.58

PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.60 - 200.68

ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.70 - 200.78

LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.80 - 200.88

OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.00 - 201.08

HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.10 - 201.18

HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.20 - 201.28

HODGKIN'S SARCOMA UNSPECIFIED SITE - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.40 - 201.48

HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES

201.50 - 201.58

HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES