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Coverage Issue for Physicians: Oral Anticancer Drugs

Claims for selected oral anticancer drugs (busulfan, capecitabine, cyclophosphamide, etoposide, fludarabine, melphalan, methotrexate, temozolomide, and topotecan) are eligible for coverage by Medicare Part B and are processed by the DME MACs.

In March 2010, the DME MACs published a revised Oral Anticancer Drugs policy which identified the ICD-9 diagnosis codes for which each drug would be covered. The DME MAC policy was revised to be consistent with Medicare's national coverage policy for Off-Label Use of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen. That policy is found in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5. (1.2 MB) The revised DME MAC policy was effective for claims with dates of service on or after June 1, 2010.

Recently, the DME MAC medical directors have become aware that the policy revision failed to include a number of diagnoses that are listed in one of the four compendia defined in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual. A revision of the DME MAC policy with a significantly expanded list of diagnoses is planned for release on August 12, 2010. Coverage for all of the added diagnoses will be retroactive to June 1, 2010.

Physicians are encouraged to work with pharmacies to ensure that their patients continue to receive the chemotherapy drugs that they have ordered.

Coverage Issue for Physicians - Oral Anticancer Drugs
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