Article for Ifosfamide (Ifex) - Related to LCD L25820 (A47579)

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 

A47579 

Article Type 

Article

Key Article 

Yes

Article Title 

Ifosfamide (Ifex) - 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 Ifosfamide 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:
Ifosfamide is classified as an alkylating agent of the nitrogen mustard type. Because of the risk of hemorrhagic cystitis, Ifosfamide is generally administered in combination with a prophylactic agent, such as mesna.

Indications:
Ifosfamide, in combination with certain other approved antineoplastic agents, is approved for germ cell testicular cancer.

Medicare will cover Ifosfamide for the treatment of the following indications:

 

  • Head and neck carcinoma
  • Soft-tissue sarcomas
  • Ewing’s sarcoma
  • Hodgkin’s lymphoma
  • Non-Hodgkin’s lymphoma
  • Breast carcinoma
  • Cervical carcinoma
  • Small cell carcinoma of the lung
  • Non-small cell carcinoma of the lung
  • Ovarian epithelial carcinoma
  • Acute lymphocytic leukemia
  • Neuroblastoma
  • Osteosarcoma
  • Germ cell ovarian tumors (in combination with other agents)
  • Bladder carcinoma (alone and in combination with other agents)
  • Endometrial carcinoma
  • Relapsed or refractory thymoma and thymic carcinoma
  • Wilms’ tumor (alone or in combination with other agents, as second-line therapy for the treatment of Wilms’ tumor in patients who have not responded to or whose disease has progressed during previous treatment)
  • Uterine carcinoma
  • Gestational trophoblastic neoplasm
  • Liver carcinoma
  • Metastatic cerebral tumor
  • Multiple myeloma
  • Nephroblastoma
  • Testicular cancer


Indications expanded by this Article:
Pancreatic carcinoma

Utilization:
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Documentation Requirements:
Medical record documentation maintained by the ordering/referring physician must substantiate the medical need for the use of Ifosfamide by clearly indicating the condition for which this drug is being used. This might include the type of cancer, staging, if applicable, prior therapy and the patient’s response to that therapy. This documentation is usually found in the history and physical or in the office/progress notes.

If the provider of the service is other than the ordering/referring physician, that provider must maintain copies of the ordering/referring physician’s order for the chemotherapy drug. The physician must state the clinical indication/medical need for using the chemotherapy drug in the order.

Coding Guidelines:

For claims submitted to the carrier or Part B MAC:

Ifosfamide 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 

 

J9208

INJECTION, IFOSFAMIDE, 1 GRAM

 

ICD-9 Codes that are Covered 

 

140.0 - 140.1

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER

140.3 - 140.6

MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT - MALIGNANT NEOPLASM OF COMMISSURE OF LIP

140.8 - 140.9

MALIGNANT NEOPLASM OF OTHER SITES OF LIP - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER

141.0 - 141.6

MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF LINGUAL TONSIL

141.8 - 141.9

MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

142.0 - 142.2

MALIGNANT NEOPLASM OF PAROTID GLAND - MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

142.8 - 142.9

MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS - MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED

143.0 - 143.1

MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF LOWER GUM

143.8 - 143.9

MALIGNANT NEOPLASM OF OTHER SITES OF GUM - MALIGNANT NEOPLASM OF GUM UNSPECIFIED

144.0 - 144.1

MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH

144.8 - 144.9

MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED

145.0 - 145.6

MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF RETROMOLAR AREA

145.8 - 145.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED

146.0 - 146.9

MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE

147.0 - 147.3

MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX - MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 - 147.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX - MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

148.0 - 148.3

MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL

148.8 - 148.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE

149.0 - 149.1

MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED - MALIGNANT NEOPLASM OF WALDEYER'S RING

149.8 - 149.9

MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

155.0-155.2

Malignant neoplasm of liver, primary – malignant neoplasm of liver, not specified as primary or secondary

157.0 - 157.4

MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 - 157.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.0

MALIGNANT NEOPLASM OF Retroperitoneum

158.8

MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM

158.9

MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

160.0 - 160.5

MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 - 160.9

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

161.0 - 161.3

MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES

161.8 - 161.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX - MALIGNANT NEOPLASM OF LARYNX 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

OTHER MALIGNANT NEOPLASM OF SKIN OF LIP

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

179

MALIGNANT NEOPLASM OF UTERUS, PART UNSPECIFIED

180.0

MALIGNANT NEOPLASM OF ENDOCERVIX

180.1

MALIGNANT NEOPLASM OF EXOCERVIX

180.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX

180.9

MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE

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 - 183.5

MALIGNANT NEOPLASM OF FALLOPIAN TUBE - MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS

183.8 - 183.9

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA - MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE

186.0

MALIGNANT NEOPLASM OF UNDESCENDED TESTIS

186.9

MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS