​L29182 GEMCITABINE (GEMZAR®) 11/15/2011 Indications and Limitations of Coverage and/or Medical Necessity Gemcitabine (Gemzar®)-J9201• Gemcitabine is FDA approved for the following indications:o In combination with paclitaxel for first-line treatment of patients with metastatic breast cancer after failure of prior anthracycline-containing adjuvant chemotherapy, unless anthracyclines are clinically contraindicated.o As first-line therapy for locally advanced (nonresectable Stage II or III) or metastatic (Stage IV) adenocarcinoma of the pancreas. It is also indicated as second-line therapy for patients who have previously been treated with fluorouracil.o In combination with cisplatin as first-line therapy for inoperable, locally advanced (Stage IIIA or IIIB) or metastatic (Stage IV) non-small cell lung carcinoma.o In combination with carboplatin for the treatment of patients with advanced ovarian cancer that has relapsed at least 6 months after completion of platinum-based therapy.• Medicare will cover Gemzar for its FDA approved uses, as well as for the treatment of the following off-labeled indications:o Primary peritoneal carcinoma.o Fallopian tube carcinoma.o Breast carcinoma.o Advanced or relapsed epithelial ovarian carcinoma used alone or in combination with other chemotherapeutic agents.o Bladder carcinoma, Metastatic bladder (urothelial) carcinoma.o Transitional cell carcinoma of kidney and ureter.o Relapsed Hodgkin’s and non-Hodgkin’s lymphoma (used alone or in combination with other agents).o Locally advanced, unresectable, or metastatic biliary tract and gallbladder carcinomaso Intrahepatic bile duct(s) carcinoma.o Testicular germ cell tumors. (Relapsed/refractory, progressive, metastatic, or nonseminomatous gonadal and extragonadal germ cell tumors).o Soft tissue sarcomas.o Germ cell tumors.o Ovarian germ cell tumors.o Advanced or recurrent endometrial carcinoma (used as a single agent or in combination with other chemotherapy drugs).o Relapsed or refractory non-Hodgkin’s lymphoma (NHL) (diffuse large B-cell lymphoma) in combination with oxaliplatin (Eloxatin) as second-line therapy. CPT/HCPCS Codes   J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG  ICD-9 Codes that Support Medical Necessity  155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS156.0 MALIGNANT NEOPLASM OF GALLBLADDER156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS156.2 MALIGNANT NEOPLASM OF AMPULLA OF VATER156.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS156.9 MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED162.0 MALIGNANT NEOPLASM OF TRACHEA162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED164.2 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM164.3 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM164.8 MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM164.9 MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP171.4 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN171.6 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS171.7 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST181 MALIGNANT NEOPLASM OF PLACENTA182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS183.0 MALIGNANT NEOPLASM OF OVARY183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS183.4 MALIGNANT NEOPLASM OF PARAMETRIUM183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE186.0 MALIGNANT NEOPLASM OF UNDESCENDED TESTIS186.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER188.5 MALIGNANT NEOPLASM OF BLADDER NECK188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE188.7 MALIGNANT NEOPLASM OF URACHUS188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED189.0* MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS189.1 MALIGNANT NEOPLASM OF RENAL PELVIS189.2 MALIGNANT NEOPLASM OF URETER194.4 MALIGNANT NEOPLASM OF PINEAL GLAND197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM198.1 SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS200.00 RETICULOSARCOMA UNSPECIFIED SITE200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES200.07 RETICULOSARCOMA INVOLVING SPLEEN200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES200.10 LYMPHOSARCOMA UNSPECIFIED SITE200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES200.17 LYMPHOSARCOMA INVOLVING SPLEEN200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES200.37 MARGINAL ZONE LYMPHOMA, SPLEEN200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES200.47 MANTLE CELL LYMPHOMA, SPLEEN200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES200.77 LARGE CELL LYMPHOMA, SPLEEN200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES201.00 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE201.01 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.02 HODGKIN'S PARAGRANULOMA INVOLVING INTRATHORACIC LYMPH NODES201.03 HODGKIN'S PARAGRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES201.04 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.05 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.06 HODGKIN'S PARAGRANULOMA INVOLVING INTRAPELVIC LYMPH NODES201.07 HODGKIN'S PARAGRANULOMA INVOLVING SPLEEN201.08 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES201.10 HODGKIN'S GRANULOMA UNSPECIFIED SITE201.11 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.12 HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES201.13 HODGKIN'S GRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES201.14 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.15 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.16 HODGKIN'S GRANULOMA INVOLVING INTRAPELVIC LYMPH NODES201.17 HODGKIN'S GRANULOMA INVOLVING SPLEEN201.18 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES201.20 HODGKIN'S SARCOMA UNSPECIFIED SITE201.21 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.22 HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES201.23 HODGKIN'S SARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES201.24 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.25 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.26 HODGKIN'S SARCOMA INVOLVING INTRAPELVIC LYMPH NODES201.27 HODGKIN'S SARCOMA INVOLVING SPLEEN201.28 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES201.40 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE201.41 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.42 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES201.43 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES201.44 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.45 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.46 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES201.47 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN201.48 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES201.50 HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE201.51 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.52 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES201.53 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES201.54 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.55 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.56 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES201.57 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN201.58 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES201.60 HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE201.61 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.62 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES201.63 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA-ABDOMINAL LYMPH NODES201.64 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.65 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.66 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES201.67 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN201.68 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES201.70 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE201.71 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.72 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES201.73 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA-ABDOMINAL LYMPH NODES201.74 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.75 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.76 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES201.77 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN201.78 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES201.90 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE201.91 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK201.92 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES201.93 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES201.94 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB201.95 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB201.96 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES201.97 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN201.98 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES202.00 NODULAR LYMPHOMA UNSPECIFIED SITE202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES202.07 NODULAR LYMPHOMA INVOLVING SPLEEN202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES202.20 SEZARY'S DISEASE UNSPECIFIED SITE202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES202.27 SEZARY'S DISEASE INVOLVING SPLEEN202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES* Note – Diagnosis code 189.0 only to be used for transitional cell cancer of the bladder residing in the kidney (renal transitional cell carcinoma).  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 might include the type of cancer, staging, if applicable, prior therapy and the patient’s response to that therapy.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• Gemcitabine is a deoxycytidine analogue antimetabolite which is structurally related to cytarabine.• In contrast to cytarabine, it has greater membrane permeability and enzyme affinity, as well as prolonged intracellular retention.• The compound acts as an inhibitor of DNA synthesis, and its mechanism of action appears to be cell-cycle specific. Sources of Information and Basis for Decision Brown, J., Smith, J., Ramondetta, L., Sood, A., Ramirez, P., Coleman, R., et al. (2010). Combination of gemcitabine and cisplatin is highly active in women with endometrial carcinoma, Cancer. Compendia-Based Drug Bulletin. (November 2010). The Association of Community Cancer Centers. [On-Line]. Available: http://www.accc-cancer.org/. FCSO LCD 29182, Gemcitabine (Gemzar®), 11/15/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, Uterine neoplasms. Version 1.2011 National Comprehensive Cancer Network (2006). Pancreatic Adenocarcinoma. Clinical Practice Guidelines in Oncology – V.1.2006. National Comprehensive Cancer Network (NCCN). (2011). NCCN Drugs & Biologics CompendiumTM: Gemcitabine hydrochloride. Retrieved from http://www.nccn.org. National Comprehensive Cancer Network (NCCN). (2011). NCCN TM Version 3.2011 Diffuse Large B-Cell Lymphoma. Retrieved from http://www.nccn.org. Thomson Micromedex (2007). 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 2010.  AMA CPT / ADA CDT Copyright StatementCPT 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. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. © Automated Clinical Guidelines, LLC 2011-2013 CMS LCD GEMCITABINE (GEMZAR®)