L28931

 

MITOXANTRONE HYDROCHLORIDE

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

Mitoxantrone hydrochloride is FDA approved for treatment of the following:

• Advanced symptomatic hormone-refractory prostate cancer (initial palliative treatment) in combination with corticosteroids.

• Acute nonlymphocytic (including myelocytic, promyelocytic, monocytic, and erythoid) leukemia in adults (used in combination with other agents).

• Secondary (chronic) progressive, progressive relapsing, or worsening relapsing-remitting multiple sclerosis.

Medicare will cover Mitoxantrone hydrochloride for its FDA approved uses, as well as for the treatment of the following off-labeled indications:

• Breast carcinoma including locally advanced and metastatic.

• Recurrent acute lymphocytic leukemia in adults.

• Non-Hodgkin’s lymphomas.

• Hepatoma in adults.

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 policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

13x Hospital Outpatient

21x Skilled Nursing - Inpatient (Including Medicare Part A)

23x Skilled Nursing - Outpatient

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0636 Pharmacy - Drugs Requiring Detailed Coding

 

 

CPT/HCPCS Codes

 

 

J9293 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG

 

 

ICD-9 Codes that Support Medical Necessity

 

 

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

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

185 MALIGNANT NEOPLASM OF PROSTATE

200.00 RETICULOSARCOMA UNSPECIFIED SITE

200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES

200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES

200.07 RETICULOSARCOMA INVOLVING SPLEEN

200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.10 LYMPHOSARCOMA UNSPECIFIED SITE

200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES

200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES

200.17 LYMPHOSARCOMA INVOLVING SPLEEN

200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE

200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES

200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES

200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN

200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK

200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES

200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES

200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES

200.37 MARGINAL ZONE LYMPHOMA, SPLEEN

200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES

200.47 MANTLE CELL LYMPHOMA, SPLEEN

200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES

200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES

200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN

200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES

200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN

200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES

200.77 LARGE CELL LYMPHOMA, SPLEEN

200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE

200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES

200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES

200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN

200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 NODULAR LYMPHOMA UNSPECIFIED SITE

202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES

202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES

202.07 NODULAR LYMPHOMA INVOLVING SPLEEN

202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE

202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES

202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES

202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN

202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES

202.20 SEZARY'S DISEASE UNSPECIFIED SITE

202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES

202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES

202.27 SEZARY'S DISEASE INVOLVING SPLEEN

202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE

202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN

202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE

202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM

202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN

202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE

202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES

202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES

202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN

202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE

202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES

202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES

202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN

202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES

202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN

202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE

202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES

202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES

202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN

202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE

202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES

202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES

202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN

202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

204.01 LYMPHOID LEUKEMIA ACUTE IN REMISSION

204.02 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE

205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

205.01 MYELOID LEUKEMIA ACUTE IN REMISSION

205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE

206.00 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

206.01 MONOCYTIC LEUKEMIA ACUTE IN REMISSION

206.02 ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE

207.00 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

207.01 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION

207.02 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE

340 MULTIPLE SCLEROSIS

 

 

Documentation Requirements

• Medical record documentation maintained by the ordering/referring physician must substantiate the medical need for the use of these chemotherapy drugs by clearly indicating the condition for which these drugs are being used.

o This documentation is usually found in the history and physical or in the office/progress notes.

• If the provider of the service is other than the ordering/referring physician, that provider must maintain copies of the ordering/referring physician’s order for the chemotherapy drug.

o The physician must state the clinical indication/medical need for using the chemotherapy drug in the order.

Treatment Logic

• Mitoxantrone hydrochloride (Novantrone®) is an anthracenedione, which inhibits DNA and RNA synthesis.

 

Sources of Information and Basis for Decision

 

Compendia-Based Drug Bulletin, August 2004. Vol. 13, No. 3. The Association of Community Cancer Centers. This source defined the indications and limitations of this drug.

 

FCSO LCD 29229, Mitoxantrone Hydrochloride, 02/02/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Lichtman, S.M., Kolitz, J., Budman, D.R., et al: Treatment of Aggressive Non-Hodgkin’s Lymphoma In Elderly Patients with Thiotepa, Novantrone (Mitoxantrone), Vincristine, Prednisone (TNOP). American Journal Clinical Oncology. 2001 Aug.; 24(4):360-2.

 

The United States Pharmacopeia Drug Information (USP DI) (March 2005) Oncology Drug Information. The Association of Community Cancer Centers (ACCC). This drug defined the FDA approved and off-labeled indications for this drug.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

© Automated Clinical Guidelines, LLC 2009-2013

 

CMS LCD MITOXANTRONE HYDROCHLORIDE