Automated World Health
Local Coverage Determination (LCD) for Paclitaxel (Taxol®) (L28943)
Contractor Information
Contractor Name
First Coast Service Options, Inc. opens in new window
Contractor Number 09101
Contractor Type MAC - Part A
LCD Information
Document Information
LCD ID Number L28943
LCD Title
Paclitaxel (Taxol®)
Contractor's Determination Number AJ9265
Primary Geographic Jurisdiction opens in new window Florida
Oversight Region Region IV
AMA CPT/ADA CDT Copyright Statement
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Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
Original Determination Effective Date
For services performed on or after 02/16/2009 Original Determination Ending Date
Revision Effective Date
Revision Ending Date
CMS National Coverage Policy
Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 30-30.1
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 10, 20 and 40 CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9-20.96 CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3
Indications and Limitations of Coverage and/or Medical Necessity
Paclitaxel (Taxol®)-J9265/paclitaxel
Paclitaxel is an antimicrotubule agent. It interferes with the normal cellular microtubule function that is required for interphase and mitosis.
Paclitaxel is FDA approved for treatment of the following indications:
• adjuvant treatment of node-positive breast cancer when administered sequentially to standard doxorubicin- containing combination chemotherapy;
• metastatic breast carcinoma after failure of combination chemotherapy or at relapse within 6 months of adjuvant chemotherapy. Prior therapy should have included an anthracycline unless clinically contraindicated;
• advanced carcinoma of ovary - first-line therapy in combination with cisplatin, and subsequent therapy;
• as a second-line treatment for AIDS-associated Kaposi’s sarcoma; and
• non-small cell lung carcinoma in combination with Cisplatin as a first-line treatment for patients who are not candidates for radiation therapy or potentially curative surgery
Medicare will cover Paclitaxel for its FDA approved uses, as well as for the treatment of the following off-labeled indications:
• First line therapy for treatment of metastatic breast cancer - as a single agent or in combination with other chemotherapy agents
• Bladder carcinoma
• Cervical carcinoma
• Endometrial carcinoma
• Esophageal carcinoma
• Head & neck carcinoma
• Small cell and non-small cell lung carcinoma
• Prostatic carcinoma
• Advanced gastric carcinoma - in combination therapy
• Malignant pleural effusion
• Cancer of Unknown Primary site (CUPs)
• Fallopian and peritoneal carcinomas of ovarian origin when used in combination with Carboplatin or Cisplatin
• Testicular germ cell carcinoma
• Soft tissue sarcomas
• Used in combination with carboplatin for the treatment of malignant melanoma
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.
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient
085x Critical Access Hospital
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
J9265 INJECTION, PACLITAXEL, 30 MG
ICD-9 Codes that Support Medical Necessity
140.0 - 149.9 opens in MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF
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ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY
150.0 - 150.9 opens in MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF
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ESOPHAGUS UNSPECIFIED SITE
151.0 - 151.9 opens in MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED
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SITE
158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
160.0 - 160.9 opens in MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ACCESSORY
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161.0 - 161.9 opens in
SINUS UNSPECIFIED
new window MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED
162.0 - 162.9 opens in MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG
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UNSPECIFIED
171.0 - 171.9 opens in MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND
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172.0 - 172.9 opens in
NECK - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE
UNSPECIFIED
new window MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED
174.0 - 174.9 opens in MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT
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NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
175.0 - 175.9 opens in MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT
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176.0 - 176.9 opens in
NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
new window KAPOSI'S SARCOMA SKIN - KAPOSI'S SARCOMA UNSPECIFIED SITE
180.0 - 180.9 opens in MALIGNANT NEOPLASM OF ENDOCERVIX - MALIGNANT NEOPLASM OF CERVIX UTERI
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UNSPECIFIED SITE
182.0 - 182.8 opens in MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS - MALIGNANT NEOPLASM
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OF OTHER SPECIFIED SITES OF BODY OF UTERUS
183.0 - 183.9 opens in MALIGNANT NEOPLASM OF OVARY - MALIGNANT NEOPLASM OF UTERINE ADNEXA
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UNSPECIFIED SITE
185 MALIGNANT NEOPLASM OF PROSTATE
186.0 - 186.9 opens in MALIGNANT NEOPLASM OF UNDESCENDED TESTIS - MALIGNANT NEOPLASM OF OTHER
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AND UNSPECIFIED TESTIS
188.0 - 188.9 opens in MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF
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BLADDER PART UNSPECIFIED
195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK
197.2 SECONDARY MALIGNANT NEOPLASM OF PLEURA
197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM
199.0 - 199.2 opens in DISSEMINATED MALIGNANT NEOPLASM - MALIGNANT NEOPLASM ASSOCIATED WITH
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TRANSPLANT ORGAN
Diagnoses that Support Medical Necessity
See ICD-9 Codes that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
All other diagnosis codes not listed as covered in the “ICD-9 Codes that Support Medical Necessity” section of this LCD.
XX000 Not Applicable
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
All other diagnoses not listed as covered in the “ICD-9 Codes that Support Medical Necessity” section of this LCD. Back to Top
General Information
Documentations 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. This might include the type of cancer, staging, if applicable, prior therapy and the patient’s response to that therapy. 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. The physician must state the clinical indication/medical need for using the chemotherapy drug in the order.
Documentation in the medical record must support paclitaxel was given for an indication specified in this Local Coverage Determination (LCD). The amount of drug, route & timing of administration, and any reaction of the patient should be documented in the medical record. In general, a facility should bill what is administered to the patient with attention to the code descriptor and quantity billed (see coding guidelines if applicable). In the event that only one patient needs a portion of the contents in the single-use vial, then the remainder can be discarded. In such a situation, the entire contents of the vial can be billed. Under no circumstances can multiple patients be billed for the entire contents of a single vial when the each patient received a portion of the drug from the same vial. With appropriate procedures, it is safe to re-enter a medication vial labeled as single use. CMS issued a procedure, developed with the approval of the Centers for Disease Control, for safe re-entry into “single-use” vials. Medicare expects this procedure to be used whenever feasible for efficient use of medications and minimal drug wastage. The hospital pharmacy record should have documentation on drugs discarded from single-use vials
that are subsequently billed to a Medicare patient.
Appendices
Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
Sources of Information and Basis for Decision
Compendia-Based Drug Bulletin. (February 2007). The Association of Community Cancer Centers. [On-Line]. Available: http://www.accc-cancer.org/.
National Comprehensive Cancer Network (2007). Ovarian Cancer. Clinical Practice Guidelines in Oncology – V.1.2007.
Rao, R., Holtan, S., Ingle, J., Croghan, G., Kottschade, L., Creagan, E., et al. (2005). Combination of paclitaxel and carboplatin as second line therapy for patients with metastatic melanoma. American Cancer Society, 375- 382.
Thomson Micromedex (2006). USP DI Drug Information for the Health Care Professional. [On-Line]. Available: http://www.thomsonhc.com/home/dispatch
U.S. Food and Drug Administration, Department of Health and Human Services, CDER web site updates, March 2007.
Zimpfer-Rechner, C., Hofmann, U., Figl, R., Becker, J., Trefzer, U., Keller, I., et al. (2003). Randomized phase II study of weekly paclitaxel versus paclitaxel and carboplatin as second-line therapy in disseminated melanoma: a multicentre trial of the Dermatologic Co-operative Oncology Group. Melanoma Research 13(5): 531-536.
Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.
Start Date of Comment Period
End Date of Comment Period
Start Date of Notice Period 12/04/2008
Revision History Number Original
Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A
Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009
LCR A2009-
December 2008 Bulletin
This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).
For Florida (00090) this LCD (L28943) replaces LCD L25122 as the policy in notice. This document (L28943) is effective on 02/16/2009.
8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0636 was changed
Reason for Change
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All Versions
Updated on 08/01/2010 with effective dates 02/16/2009 - N/A Updated on 08/01/2010 with effective dates 02/16/2009 - N/A Updated on 11/30/2008 with effective dates 02/16/2009 - N/A Read the LCD Disclaimer opens in new window