Article for Irinotecan Hydrochloride (e.g., Camptosar®) - Related to LCD L25820 (A46757)

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 

A46757 

Article Type 

Article

Key Article 

Yes

Article Title 

Irinotecan Hydrochloride (e.g., Camptosar®) - 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 

03/01/2008

 

Article Revision Effective Date 

01/01/2009

 

Article Text 

This article defines coding and coverage for irinotecan hydrocloride 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:
Irinotecan hydrochloride is an intravenous, antineoplastic agent. It is a semisynthetic alkaloid precursor derived from camptothecin, a plant extract. Irinotecan interacts with the enzyme topoisomerase I, to prevent repair of single-strand DNA breaks. This damages double-stranded DNA and leads to cell death.

Indications:

  • Irinotecan is used in the treatment of patients with colorectal cancer
  • Non-small-cell lung carcinoma (NSCLC)
  • Small cell lung carcinoma (SCLC)
  • Cervical cancer
  • Esophageal and gastric cancer
  • Acute lymphoid leukemia
  • Acute myeloid leukemia
  • Metastatic breast cancer, refractory
  • Non-Hodgkin’s lymphoma
  • Ovarian cancer, platinum-refractory or platinum-resistant
  • Malignant glioma of brain, recurrent or progressive disease


Indications expanded by this Article

  • Carcinoma of small intestine
  • Pancreatic cancer


Utilization:

  • Weekly dosage schedule-Recommended starting dose in adults is 125 mg/m² once a week for 4 weeks, followed by a 2-week rest period.
  • Once-every-3-week dosage schedule-Recommended starting dose is 350 mg/m². The recommended treatment regimen (one course) is once every 3 weeks.
  • Once every-2-week schedule-Recommended starting dose is 180 mg/m².
    For all three schedules, treatment with additional courses may be continued as long as there is a continuous response, stability is maintained, or therapy can be tolerated. Additional courses of treatment may be repeated every 6 weeks. All doses should be administered as an intravenous (IV) infusion over 90 minutes.


Coding Guidelines:

For claims submitted to the carrier or Part B MAC:

Irinotecan 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 

 

J9206

INJECTION, IRINOTECAN, 20 MG

 

ICD-9 Codes that are Covered 

 

150.0

MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS

150.1

MALIGNANT NEOPLASM OF THORACIC ESOPHAGUS

150.2

MALIGNANT NEOPLASM OF ABDOMINAL ESOPHAGUS

150.3

MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS

150.4

MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS

150.5

MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS

150.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS

150.9

MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE

151.0

MALIGNANT NEOPLASM OF CARDIA

151.1

MALIGNANT NEOPLASM OF PYLORUS

151.2

MALIGNANT NEOPLASM OF PYLORIC ANTRUM

151.3

MALIGNANT NEOPLASM OF FUNDUS OF STOMACH

151.4

MALIGNANT NEOPLASM OF BODY OF STOMACH

151.5

MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH UNSPECIFIED

151.6

MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH

151.9

MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

152.0

MALIGNANT NEOPLASM OF DUODENUM

152.1

MALIGNANT NEOPLASM OF JEJUNUM

152.2

MALIGNANT NEOPLASM OF ILEUM

152.3

MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM

152.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE

152.9

MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

153.0

MALIGNANT NEOPLASM OF HEPATIC FLEXURE

153.1

MALIGNANT NEOPLASM OF TRANSVERSE COLON

153.2

MALIGNANT NEOPLASM OF DESCENDING COLON

153.3

MALIGNANT NEOPLASM OF SIGMOID COLON

153.4

MALIGNANT NEOPLASM OF CECUM

153.5

MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS

153.6

MALIGNANT NEOPLASM OF ASCENDING COLON

153.7

MALIGNANT NEOPLASM OF SPLENIC FLEXURE

153.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9

MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

154.0

MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

154.1

MALIGNANT NEOPLASM OF RECTUM

154.2

MALIGNANT NEOPLASM OF ANAL CANAL

154.3

MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8

MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

157.0

MALIGNANT NEOPLASM OF HEAD OF PANCREAS

157.1

MALIGNANT NEOPLASM OF BODY OF PANCREAS

157.2

MALIGNANT NEOPLASM OF TAIL OF PANCREAS

157.3

MALIGNANT NEOPLASM OF PANCREATIC DUCT

157.4

MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS

157.9

MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

162.0

MALIGNANT NEOPLASM OF TRACHEA

162.2

MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3

MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4

MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5

MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8

MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9

MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

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

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

183.0

MALIGNANT NEOPLASM OF OVARY

183.2

MALIGNANT NEOPLASM OF FALLOPIAN TUBE

183.3

MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS

183.4

MALIGNANT NEOPLASM OF PARAMETRIUM

183.5

MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS

183.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA

183.9

MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE

191.0<