Article for Oprelvekin (e.g., Neumega®) – Related to LCD L25820 (A46098)

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 

A46098 

Article Type 

Article

Key Article 

Yes

Article Title 

Oprelvekin (e.g., Neumega®) – 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 

12/01/2007

 

Article Revision Effective Date 

01/01/2009

 

Article Text 

This article defines coding and coverage for oprelvekin 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.


Indications:
Oprelvekin is indicated for the prevention of severe thrombocytopenia and the reduction of the need for platelet transfusions following myelosuppressive chemotherapy in adult patients with nonmyeloid malignancies who are at high risk of severe thrombocytopenia.

Coding Guidelines:

General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC:


A primary diagnosis (ICD-9-CM code 287.4 or 909.5) and a secondary diagnosis (ICD-9-CM code 140.0 - 202.98) must be reported on claims submitted for oprelvekin.

For claims submitted to the carrier or Part B MAC:

Oprelvekin should not be billed using chemotherapy administration codes and is payable in the following places of service: office (11), home (12), assisted living facility (13), group home (14), custodial care facility (33), independent clinic (49) and state or local public health clinic (71), only when supplied as an “incident to” service by the physician.

 

Coverage Topic 

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 

 

J2355

INJECTION, OPRELVEKIN, 5 MG

 

ICD-9 Codes that are Covered 

Primary ICD-9-CM codes

 

287.4

SECONDARY THROMBOCYTOPENIA

909.5

LATE EFFECT OF ADVERSE EFFECT OF DRUG MEDICINAL OR BIOLOGICAL SUBSTANCE


Secondary ICD-9-CM codes

140.0

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER

140.1

MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER

140.3

MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT

140.4

MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT

140.5

MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT

140.6

MALIGNANT NEOPLASM OF COMMISSURE OF LIP

140.8

MALIGNANT NEOPLASM OF OTHER SITES OF LIP

140.9

MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER

141.0

MALIGNANT NEOPLASM OF BASE OF TONGUE

141.1

MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE

141.2

MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE

141.3

MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE

141.4

MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED

141.5

MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE

141.6

MALIGNANT NEOPLASM OF LINGUAL TONSIL

141.8

MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE

141.9

MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

142.0

MALIGNANT NEOPLASM OF PAROTID GLAND

142.1

MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND

142.2

MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

142.8

MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS

142.9

MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED

143.0

MALIGNANT NEOPLASM OF UPPER GUM

143.1

MALIGNANT NEOPLASM OF LOWER GUM

143.8

MALIGNANT NEOPLASM OF OTHER SITES OF GUM

143.9

MALIGNANT NEOPLASM OF GUM UNSPECIFIED

144.0

MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH

144.1

MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH

144.8

MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH

144.9

MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED

145.0

MALIGNANT NEOPLASM OF CHEEK MUCOSA

145.1

MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH

145.2

MALIGNANT NEOPLASM OF HARD PALATE

145.3

MALIGNANT NEOPLASM OF SOFT PALATE

145.4

MALIGNANT NEOPLASM OF UVULA

145.5

MALIGNANT NEOPLASM OF PALATE UNSPECIFIED

145.6

MALIGNANT NEOPLASM OF RETROMOLAR AREA

145.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH

145.9

MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED

146.0

MALIGNANT NEOPLASM OF TONSIL

146.1

MALIGNANT NEOPLASM OF TONSILLAR FOSSA

146.2

MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)

146.3

MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA

146.4

MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS

146.5

MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX

146.6

MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX

146.7

MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX

146.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX

146.9

MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE

147.0

MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX

147.1

MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX

147.2

MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX

147.3

MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX

147.9

MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

148.0

MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX

148.1

MALIGNANT NEOPLASM OF PYRIFORM SINUS

148.2

MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT

148.3

MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL

148.8

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX

148.9

MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE

149.0

MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED

149.1

MALIGNANT NEOPLASM OF WALDEYER'S RING

149.8

MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY

149.9

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

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 NEO