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Contractor Name

CareFirst INC., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L16596 

LCD Title

Irinotecan Hydrochloride (CamptosarÒ)

Contractor’s Determination Number

04-03

AMA/CPT and ADA/CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. CDT-4 codes and descriptions are © 2004 American Dental Association. All rights reserved.

CMS National Coverage Policy

  • Establishment of national policy supersedes all previous contractor policy statements, including Local Coverage Determinations.
  • Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
  • Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

DMERC Region LCD Covers

N/A

Original Determination Effective Date

08/02/2004 

Revision Effective Date

 

Indications and Limitations of Coverage and/or Medical Necessity

Description

Irinotecan is an intravenous antineoplastic agent.  It is a semi synthetic alkaloid precursor derived from camptothecin, a plant extract.  Irinotecan interacts with the enzyme topoisomerage I, to prevent repair of single-strand DNA breaks.  This damages double-strained DNA and leads to cell death.

 

Indications

·         Irinotecan is used as the first-line therapy for the treatment of patients with metastatic colorectal cancer in combination with 5-fluorouracil/leucovorin.

·         Irinotecan is used in the treatment of patients with metastatic colorectal cancer after failure of first-line (5-FU) chemotherapy.

·         Irinotecan is used in the treatment of patients with refractory or relapsed lung cancer.

Coverage Topics

Chemotherapy (Outpatient)

Outpatient Hospital Services

Bill Type Codes

13X, 21X, 85X

Revenue Codes

636

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

J9206

 

Irinotecan, 20 mg

 

Does the “CPT 30% Rule Apply?

N/A

 

ICD-9-CM Codes that Support Medical Necessity

 

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid

Medicare is establishing the following limited coverage:

153.0

 

Malignant neoplasm of colon, hepatic flexure

153.1

 

Malignant neoplasm of colon, transverse colon

153.2

 

Malignant neoplasm of colon, descending colon

153.3

 

Malignant neoplasm of colon, sigmoid colon

153.4

 

Malignant neoplasm of colon, cecum

153.5

 

Malignant neoplasm of colon, appendix

153.6

 

Malignant neoplasm of colon, ascending colon

153.7

 

Malignant neoplasm of colon, splenic flexure

153.8

 

Malignant neoplasm of colon, other specified sites of large intestine

153.9

 

Malignant neoplasm of colon, other

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

154.8

 

Malignant neoplasm of rectum, rectosigmoid junction and anus, other

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 trachea, bronchus, lung, unspecified

180.0

 

Malignant neoplasm of cervix uteri, endocervix

180.1

 

Malignant neoplasm of cervix uteri, exocervix

180.8

 

Malignant neoplasm of cervix uteri, other specified sites of cervix

180.9

 

Malignant neoplasm of cervix uteri, cervix uteri, unspecified

 

Diagnoses that Support Medical Necessity

N/A

 

ICD-9-Codes that DO NOT Support Medical Necessity

N/A

 

Diagnoses that DO NOT Support Medical Necessity

N/A

 

Documentation Requirements

·         Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request. 

Utilization Guidelines

·        Medicare will monitor the utilization of this service through the Medical Review process.

Sources of Information and Basis for Decision

·        TrailBlazer local policy

·        Veritus Medicare local policy

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with representatives from (specialty group)

Start Date of Comment Period

 04/16/2004

End Date of Comment Period

 06/01/2004

Start Date of Notice Period

06/18/2004 

Revision History Number

 

Revision History Explanation

Revision Number

Revision History Explanation

 

 

 

Does this LMRP contain a “Least Costly Alternative” provision?

No

 

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com