| |
 |
Medical Policy Bulletin
| Title: | Bevacizumab (Avastin®) |
 |
|
The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site. |
| |
 Intent |
|
The intent of this policy is to communicate the medical necessity criteria for bevacizumab (Avastin®).
For information on policies related to this topic, refer to the Cross References section in this policy. |
| Description |
|
Bevacizumab (Avastin®) is a recombinant humanized monoclonal IgG1 antibody that works by binding to and inhibiting the action of vascular endothelial growth factor (VEGF). VEGF is a substance that binds to certain cells to stimulate new blood vessel formation (angiogenesis). When VEGF is bound to bevacizumab (Avastin®), it cannot stimulate the formation and growth of new blood vessels. Bevacizumab (Avastin®) is thought to enhance the effects of chemotherapy.
The US Food and Drug Administration (FDA) has granted approval for the use of bevacizumab (Avastin®) for the following indications:
- In individuals who have metastatic carcinoma of the colon or rectum, as first- or second-line treatment, in combination with intravenous 5-fluorouracil-based chemotherapy
- In individuals who have unresectable, locally advanced, recurrent, or metastatic non-squamous non-small cell lung cancer, as first-line treatment in combination with paclitaxel (Taxol®) and carboplatin (Paraplatin®)
- In individuals who have not received chemotherapy for metastatic HER2-negative breast cancer, in combination with paclitaxel (Taxol®)
- In individuals who have glioblastoma with progressive disease following prior therapy, as a single agent
- The FDA labeling states that the effectiveness of bevacizumab (Avastin®) in glioblastoma is based on an improvement in objective response rate. There are no data demonstrating an improvement in disease-related symptoms or increased survival with bevacizumab (Avastin®).
- In individuals who have metastatic renal cell carcinoma, in combination with interferon alfa
The FDA labeling notes that bevacizumab (Avastin®) is not indicated for individuals who have breast cancer that has progressed following the administration of anthracycline and taxane chemotherapy for metastatic disease.
Bevacizumab (Avastin®) is also recognized as an appropriate medical treatment in published clinical research and drug compendia or in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology when used for the following indications:
- In individuals who have metastatic breast carcinoma, as first-line treatment in combination with paclitaxel (Taxol®) regardless of HER2 status
- In individuals who have metastatic carcinoma of the colon or rectum, as first- or second-line treatment, in combination with capecitabine (Xeloda®)-based chemotherapy
- In individuals who have recurrent epithelial ovarian cancer, as a single agent for the following indications:
- Recurrence as evidenced by serially rising CA-125 in individuals who have received prior chemotherapy for ovarian cancer
- Progressive or stable disease on primary therapy
- Relapse after being in complete remission following primary chemotherapy
- Stage II to IV disease showing partial response to primary therapy
- In individuals who have advanced, recurrent, or metastatic non-squamous non-small cell lung cancer, with a good performance status (PS 0-1), no history of hemoptysis, and no untreated central nervous system (CNS) metastases as first-line treatment in combination with a cisplatin-based or carboplatin-based regimen (ie, a regimen with any of the following agents: paclitaxel, docetaxel, gemcitabine, vinorelbine, irinotecan, etoposide, vinblastine, pemetrexed)
- Bevacizumab (Avastin®) should not be given as a single agent, unless as maintenance if initially used with chemotherapy.
- In individuals who have renal cell carcinoma with predominant clear cell histology for either of the following:
- As first-line treatment in combination with interferon alfa-2a for relapsed or medically unresectable Stage IV disease
- As subsequent, single-agent therapy for individuals who have relapsed or medically unresectable Stage IV disease that has progressed on prior first-line therapy
- As intravitreal injection for individuals who have any of the following vascular diseases of the eye:
- Wet, age-related macular degeneration (AMD)
- Ischemic retinal vein occlusions
- Proliferative diabetic retinopathy, when used to decrease vascularity prior to vitreous surgery
- In individuals who have progression following a prior therapy or recurrent Grade III or IV glioma (ie, anaplastic astrocytoma/anaplastic oligodendroglioma, mixed anaplastic oligoastrocytoma, glioblastoma multiforme [GBM]), as a single agent or in combination with irinotecan (Campto®)
- A Grade III or IV glioma is based on the World Health Organization (WHO) grading system for astrocytomas. Gliomas are classified by the type of cell (eg, astrocytomas, oligodendrogliomas, oligoastrocytomas) and their pathology grade. Low-grade gliomas (Grade I and II) are benign tumors with a well-differentiated cell. High-grade gliomas (Grade III and IV) are undifferentiated or anaplastic (malignant). Anaplastic astrocytoma/anaplastic oligodendroglioma, and mixed anaplastic oligoastrocytoma are classified as WHO Grade III gliomas, whereas GBM is a WHO Grade IV glioma.
Clinical research on the use of bevacizumab (Avastin®) in the treatment of other cancers is ongoing.
Whether bevacizumab (Avastin®) has an effect on health outcomes for individuals with those types of cancer has yet to be determined. |
| Policy |
|
Bevacizumab (Avastin®) is considered medically necessary and, therefore, covered for the following indications:
Breast carcinoma
- In individuals who have metastatic breast carcinoma, as first-line treatment in combination with paclitaxel (Taxol®)
Colorectal carcinoma
- In individuals who have metastatic carcinoma of the colon or rectum, as first- or second-line treatment, in combination with intravenous 5-fluorouracil-based chemotherapy (eg, IFL [irinotecan, fluorouracil, leucovorin], FOLFOX4 [oxaliplatin, leucovorin, fluorouracil]), or with capecitabine (Xeloda®)-based chemotherapy
Epithelial ovarian cancer, recurrent
- In individuals who have recurrent epithelial ovarian cancer, as a single agent for any of the following indications:
- Recurrence as evidenced by serially rising CA-125 in individuals who have received prior chemotherapy for ovarian cancer
- Progressive or stable disease on primary therapy
- Relapse after being in complete remission following primary chemotherapy
- Stage II to IV disease showing partial response to primary therapy
Glioma, recurrent (Grade III or IV)
- In individuals who have progression following a prior therapy or recurrent Grade III or IV glioma (ie, anaplastic astrocytoma/anaplastic oligodendroglioma, mixed anaplastic oligoastrocytoma, glioblastoma multiforme [GBM]), as a single agent or in combination with irinotecan (Campto®)
Non-squamous non-small cell lung cancer
- In individuals who have unresectable, locally advanced, recurrent, or metastatic non-squamous non-small cell lung cancer, as first-line treatment in combination with paclitaxel (Taxol®) and carboplatin (Paraplatin®)
- In individuals who have advanced, recurrent, or metastatic non-squamous non-small cell lung cancer, with a good performance status (PS 0-1), no history of hemoptysis, and no untreated central nervous system (CNS) metastases as first-line treatment in combination with a cisplatin-based or carboplatin-based regimen (ie, a regimen with any of the following agents: paclitaxel, docetaxel, gemcitabine, vinorelbine, irinotecan, etoposide, vinblastine, pemetrexed)
- Bevacizumab (Avastin®) should not be given as a single agent, unless as maintenance if initially used with chemotherapy.
- For information on performance status as defined by the Eastern Cooperative Oncology Group (ECOG), please refer to the Guidelines section in this policy.
Renal cell carcinoma
- In individuals who have metastatic renal cell carcinoma (mRCC) for either of the following:
- As treatment of mRCC in combination with interferon alfa
- As a subsequent, single-agent therapy for individuals who have relapsed or medically unresectable Stage IV disease of predominant clear cell histology that has progressed on prior first-line therapy
Vascular diseases of the eye
- Intravitreal injection for individuals who have any of the following vascular diseases of the eye:
- Wet, age-related macular degeneration (AMD)
- Ischemic retinal vein occlusions
- Proliferative diabetic retinopathy, when used to decrease vascularity prior to vitreous surgery
BILLING REQUIREMENTS
AS PART OF A CHEMOTHERAPEUTIC REGIMEN
To report bevacizumab (Avastin®) as part of a chemotherapeutic regimen, use the following HCPCS code:
- J9035: Injection, bevacizumab, 10 mg
FOR INTRAVITREAL INJECTION
To ensure an optimal level of reimbursement, all providers must report the intravitreal injection of bevacizumab (Avastin®) with both a HCPCS procedure code and an ICD-9 diagnosis code, as outlined below:
- Please be sure to report HCPCS code J9035: Injection, bevacizumab, 10 mg (for any date of administration)
Note: The HCPCS code Q2024: Injection, bevacizumab, 0.25 mg is a deleted code as of 12/31/09. Q2024 can be used to bill for dates of administration from the code effective date of 10/01/09 until the code deletion date of 12/31/09.
- The specific ICD-9 diagnosis code that represents any of the following vascular diseases of the eye (please refer to the Coding Table in this policy for the specific codes):
- Wet AMD
- Ischemic retinal vein occlusions
- Proliferative diabetic retinopathy, when used to decrease vascularity prior to vitreous surgery
PRECERTIFICATION OR PREAPPROVAL REQUIREMENTS
For most of the Company's products, bevacizumab (Avastin®) requires precertification or preapproval, regardless of place of service, with the exception of the following:
- Precertification or preapproval for intravitreal injection of bevacizumab (Avastin®) for the ophthalmologic conditions listed in this policy is not required for individuals who are enrolled in a Pennsylvania or Delaware product when the billing requirements listed above are followed.
Individual product requirements must be verified.
EXPERIMENTAL/INVESTIGATIONAL
All other uses of bevacizumab (Avastin®) are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the medical policy on off-label coverage for prescription drugs and biologics. Uses of bevacizumab (Avastin®) that are not supported in either this medical policy or the off-label coverage policy are considered experimental/investigational and, therefore, not covered.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service. |
|
| Guidelines |
|
The following information was taken directly from the product labeling for bevacizumab (Avastin®) that existed at the time this policy was developed:
BLACK BOX WARNINGS
GASTROINTESTINAL PERFORATIONS
The incidence of gastrointestinal perforation, some fatal, in Avastin-treated patients ranges from 0.3 to 2.4%. Discontinue Avastin in patients with gastrointestinal perforation.
SURGERY AND WOUND HEALING COMPLICATIONS
The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients. Discontinue Avastin in patients with wound dehiscence. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined. Discontinue at least 28 days prior to elective surgery. Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed.
THE EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) PERFORMANCE STATUS
The ECOG has developed the ECOG Performance Status; it was originally published in 1982 in the American Journal of Clinical Oncology*. ECOG states, "These scales and criteria are used by doctors and researchers to assess how a patient's disease is progressing, assess how the disease affects the daily living abilities of the patient, and determine appropriate treatment and prognosis. They are included here for health care professionals to access."
ECOG Performance Status |
Grade | ECOG |
0 | Fully active, able to carry on all pre-disease performance without restriction |
1 | Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, eg, light house work, office work |
2 | Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50 percent of waking hours |
3 | Capable of only limited self care, confined to bed or chair more than 50 percent of waking hours |
4 | Completely disabled. Cannot carry on any self care: Totally confined to bed or chair |
5 | Dead |
*Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol.1982;5(6):649-655.
BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, bevacizumab (Avastin®) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.
A medication or class of medications may be a product or group contract exclusion. Individual benefits must be verified.
MEDICARE
This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.
For Medicare Advantage members, bevacizumab (Avastin®) is available through either the member's medical benefit (Part B benefit) or pharmacy benefit (Part D benefit), depending on how the drug is prescribed, dispensed, or administered. This medical policy only addresses instances when bevacizumab (Avastin®) is covered under a member's medical benefit. It does not address instances when bevacizumab (Avastin®) is covered under a member’s pharmacy benefit.
US FOOD AND DRUG ADMINISTRATION (FDA) STATUS
The initial approval for the use of bevacizumab (Avastin®) was granted by the FDA on February 26, 2004. Supplemental approvals have since been issued. |
| References |
|
Avery RL, Pearlman J, Pieramici DJ, et al. Intravitreal bevacizumab (Avastin) in the treatment of proliferative diabetic retinopathy. Ophthalmology. 2006;113(10):1695.e1-e15.
Bevacizumab (Avastin®). American Hospital Formulary Service (AHFS). Drug Information 2009. [STAT!Ref Web site]. Available at: http://online.statref.com [via subscription only]. Accessed August 4, 2009.
Bevacizumab (Avastin®). Micromedex® Healthcare Series. [Micromedex® Web site]. July 2009. Available at: http://www.thomsonhc.com [via subscription only]. Accessed August 4, 2009.
Bhavsar AR, Atebara NH, Drouilhet JH. Retinopathy, diabetic, proliferative. [eMedicine Web site]. 03/11/09. Available at: http://www.emedicine.com/oph/topic415.htm. Accessed August 4, 2009.
BlueCross BlueShield Association (BCBSA) Technology Evaluation Center. Off-label uses of bevacizumab: Renal cell carcinoma and other miscellaneous non-colorectal cancer indications [technology assessment]. Assessment Program Volume 21, No. 9. October 2006.
BlueCross BlueShield Association (BCBSA) Technology Evaluation Center. Special report: Current and evolving strategies in the treatment of age-related macular degeneration [technology assessment]. Assessment Program Volume 20, No. 11. December 2005.
Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Publication 100-04: Medicare claims processing. Transmittal 588: Coverage of colorectal anti-cancer drugs included in clinical trials. [CMS Web site]. 06/17/05. Available at: http://www.cms.hhs.gov/Transmittals/downloads/R588CP.pdf. Accessed August 4, 2009.
Ciulla TA, Amador AG, Zinman B. Diabetic retinopathy and diabetic macular edema: pathophysiology, screening, and novel therapies. Diabetes Care. 2003;26(9):2653-2664.
Eastern Cooperative Oncology Group (ECOG). ECOG performance status. [ECOG Web site]. 07/27/06. Available at: http://ecog.dfci.harvard.edu/general/perf_stat.html. Accessed August 4, 2009.
Haritoglou C, Kook D, Neubauer A, et al. Intravitreal bevacizumab (Avastin) therapy for persistent diffuse diabetic macular edema. Retina. 2006;26(9):999-1005.
Highmark Medicare Services. Local Coverage Determination (LCD).L27473: Approved drugs and biologicals. [Highmark Medicare Services Web site]. Original: 07/11/08. (Revised: 12/12/08). Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27473-r4.html. Accessed August 4, 2009.
Highmark Medicare Services. Local Coverage Determination (LCD).L27477: Cancer chemotherapeutic agents. [Highmark Medicare Services Web site]. Original: 07/11/08. (Revised: 12/12/08). Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27477-r5.html. Accessed August 4, 2009.
Highmark Medicare Services. What's New? Bevacizumab (Avastin®). [Highmark Medicare Services Web site]. 08/07/06. Available at: http://www.highmarkmedicareservices.com/partb/whatsnew/2006.html. Accessed August 4, 2009.
Iturralde D, Spaide RF, Meyerle CB, et al. Intravitreal bevacizumab (Avastin) treatment of macular edema in central retinal vein occlusion: a short-term study. Retina. 2006;26(3):279-284.
Jorge R, Costa RA, Calucci D, Cintra LP, Scott IU. Intravitreal bevacizumab (Avastin) for persistent new vessels in diabetic retinopathy (IBEPE study). Retina. 2006;26(9):1006-1013.
Kennedy B, Bruce JN. Astrocytoma. [eMedicine Web site]. 01/23/09. Available at: http://www.emedicine.com/med/TOPIC2693.HTM. Accessed August 4, 2009.
National Cancer Institute (NCI). Clinical trials covered under the Medicare Anti-Cancer Drugs National Coverage Decision. [NCI Web site]. 07/17/09. Available at: http://www.cancer.gov/clinicaltrials/developments/NCD179N. Accessed August 4, 2009.
National Cancer Institute (NCI). Ovarian epithelial cancer treatment (PDQ®). Health professional version. [NCI Web site]. 04/16/09. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/ovarianepithelial/HealthProfessional/page1. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Breast cancer. v.1.2009. [NCCN Web site]. 12/02/08. Available at: http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Central nervous system cancers. v.2.2009. [NCCN Web site]. 07/27/09. Available at: http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Colon cancer. v.2.2009. [NCCN Web site]. 03/03/09. Available at:
http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Kidney cancer. v.2.2009. [NCCN Web site]. 04/13/09. Available at: http://www.nccn.org/professionals/physician%5Fgls/PDF/kidney.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Non-small cell lung cancer. v.2.2009. [NCCN Web site]. 10/15/08. Available at: http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Ovarian cancer, including fallopian tube cancer and primary peritoneal cancer. v.2.2009. [NCCN Web site]. 05/21/09. Available at: http://www.nccn.org/professionals/physician_gls/PDF/ovarian.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Pancreatic adenocarcinoma. v.1.2009. [NCCN Web site]. 03/26/09. Available at: http://www.nccn.org/professionals/physician_gls/PDF/pancreatic.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Rectal cancer. v.2.2009. [NCCN Web site]. 03/03/09 Available at: http://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf. Accessed August 14, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Small cell lung cancer. v.2.2009. [NCCN Web site]. 09/19/08. Available at: http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf. Accessed August 4, 2009.
National Comprehensive Cancer Network (NCCN). NCCN Drugs & Biologics Compendium™.Bevacizumab (Avastin®). [NCCN Web site]. Available at: http://www.nccn.org/professionals/drug_compendium/content/contents.asp [via subscription only]. Accessed August 4, 2009.
National Eye Institute (NEI). Diabetic retinopathy. [NEI Web site]. September 2009. Available at: http://www.nei.nih.gov/health/diabetic/retinopathy.asp. Accessed September 15, 2009.
Pai SA, Shetty R, Vijayan PB, et al. Clinical, anatomic, and electrophysiologic evaluation following intravitreal bevacizumab for macular edema in retinal vein occlusion. Am J Ophthalmol. 2007;143(4):601-606.
Peretti P, Brunel H, Barrie M, Chinot O. Oligodendroglioma. [eMedicine Web site]. 12/22/08. Available at: http://www.emedicine.com/radio/topic481.htm. Accessed August 4, 2009.
Pope WB, Lai A, Nghiemphu P, Mischel P, Cloughesy TF. MRI in patients with high-grade gliomas treated with bevacizumab and chemotherapy. Neurology. 2006;66(8):1258-1260.
Salah Uddin ABM, Jarmi T. Glioblastoma multiforme. [eMedicine Web site]. 09/08/09. Available at: http://www.emedicine.com/neuro/TOPIC147.HTM. Accessed September 15 2009.
US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Avastin (bevacizumab). Package insert. [FDA Web site]. July 2009. Available at:
http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/125085s0168lbl.pdf. Accessed August 4, 2009.
US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs@FDA. Drug details: Avastin (bevacizumab). [FDA Web site]. 08/31/09. Available at: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Label_ApprovalHistory#apphist. Accessed August 4, 2009.
US Food and Drug Administration (FDA). Safety information. Avastin (bevacizumab). [FDA Web site]. 07/14/08. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm075132.htm. Accessed August 4, 2009.
Vredenburgh JJ, Desjardins A, Herndon JE 2nd, et al. Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clin Cancer Res. 2007;13(4):1253-1259. |
| Coding Table |
|
Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company. |
|
| Code System | Code Number(s) and Narrative(s) |
| CPT | N/A |
| ICD Procedure | N/A |
| ICD Diagnosis | TO REPORT METASTATIC BREAST CANCER, USE THE FOLLOWING CODES
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
V10.3: Personal history of malignant neoplasm of breast
TO REPORT METASTATIC CARCINOMA OF THE COLON, USE THE FOLLOWING CODES
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
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
209.10: Malignant carcinoid tumor of the large intestine, unspecified portion
209.11: Malignant carcinoid tumor of the appendix
209.12: Malignant carcinoid tumor of the cecum
209.13: Malignant carcinoid tumor of the ascending colon
209.14: Malignant carcinoid tumor of the transverse colon
209.15: Malignant carcinoid tumor of the descending colon
209.16: Malignant carcinoid tumor of the sigmoid colon
V10.05: Personal history of malignant neoplasm of large intestine
TO REPORT METASTATIC CARCINOMA OF THE RECTUM, USE THE FOLLOWING CODES
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
209.17: Malignant carcinoid tumor of the rectum
V10.06: Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
TO REPORT RECURRENT EPITHELIAL OVARIAN CANCER, USE THE FOLLOWING CODES
183.0: Malignant neoplasm of ovary
183.2: Malignant neoplasm of fallopian tube
198.6: Secondary malignant neoplasm of ovary
TO REPORT RECURRENT GLIOMA (GRADE III OR IV), USE THE FOLLOWING CODES
191.0: Malignant neoplasm of cerebrum, except lobes and ventricles
191.1: Malignant neoplasm of frontal lobe of brain
191.2: Malignant neoplasm of temporal lobe of brain
191.3: Malignant neoplasm of parietal lobe of brain
191.4: Malignant neoplasm of occipital lobe of brain
191.5: Malignant neoplasm of ventricles of brain
191.6: Malignant neoplasm of cerebellum NOS
191.7: Malignant neoplasm of brain stem
191.8: Malignant neoplasm of other parts of brain
191.9: Malignant neoplasm of brain, unspecified site
TO REPORT METASTATIC NON-SQUAMOUS NON-SMALL CELL LUNG CANCER, USE THE FOLLOWING CODES
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 site
V10.11: Personal history of malignant neoplasm of bronchus and lung
TO REPORT RENAL CELL CARCINOMA, USE THE FOLLOWING CODES
189.0: Malignant neoplasm of kidney, except pelvis
189.1: Malignant neoplasm of renal pelvis
TO REPORT MACULAR DEGENERATION, USE THE FOLLOWING CODE
362.52: Exudative senile macular degeneration of retina
TO REPORT ISCHEMIC RETINAL VEIN OCCLUSION, USE THE FOLLOWING CODES
362.30: Unspecified retinal vascular occlusion
362.35: Central vein occlusion of retina
362.36: Venous tributary (branch) occlusion of retina
362.37: Venous engorgement of retina
TO REPORT PROLIFERATIVE DIABETIC RETINOPATHY, USE THE FOLLOWING CODES
249.50: Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified
249.51: Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled
250.50: Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
250.51: Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled
250.52: Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
250.53: Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled
362.02: Proliferative diabetic retinopathy |
| HCPCS Level II | TO REPORT BEVACIZUMAB (AVASTIN®) AS PART OF A CHEMOTHERAPEUTIC REGIMEN, USE THE FOLLOWING CODE
J9035: Injection, bevacizumab, 10 mg
TO REPORT BEVACIZUMAB (AVASTIN®) GIVEN BY INTRAVITREAL INJECTION, USE THE FOLLOWING CODE
J9035: Injection, bevacizumab, 10 mg |
| |
| Revenue Codes | N/A |
| Cross References |
| Cross Reference Policies |
|
|
|
| Version Effective Date: 01/01/2010 | |
| |
 |
The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2010 AmeriHealth, Inc. All Rights Reserved. Current Procedural Terminology ©2010 American Medical Association. All Rights Reserved. |
|
|