LCD/NCD Portal

L29187

 

HEMOPHILIA CLOTTING FACTORS

 

 

01/01/2012

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Medicare provides coverage of self-administered blood clotting factors for hemophilia patients who are competent to use such factors to control bleeding without medical supervision.

• Medicare covers blood clotting factors for the following conditions:

o Factor VIII deficiency (classic hemophilia, hemophilia A).

o Factor IX deficiency (hemophilia B, Christmas disease, plasma thromboplastin component).

o Von Willebrand’s disease.

• Anti-inhibitor coagulant complex (AICC) is a drug used to treat hemophilia in patients with Factor VIII inhibitor antibodies.

• AICC has been shown to be safe and effective and is covered by Medicare when furnished to patients with hemophilia A and inhibitor antibodies to Factor VIII who have major bleeding episodes and who fail to respond to other less expensive therapies.

 

 

CPT/HCPCS Codes

 

J7183 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I.U. VWF:RCO

J7187 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO

J7189 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM

J7190 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.

J7191 FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.

J7192 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE SPECIFIED

J7193 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.

J7194 FACTOR IX, COMPLEX, PER I.U.

J7195 FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.

J7198 ANTI-INHIBITOR, PER I.U.

XX000 Not Applicable

 

 

ICD-9 Codes that Support Medical Necessity

 

286.0 CONGENITAL FACTOR VIII DISORDER

286.1 CONGENITAL FACTOR IX DISORDER

286.2 CONGENITAL FACTOR XI DEFICIENCY

286.3 CONGENITAL DEFICIENCY OF OTHER CLOTTING FACTORS

286.4 VON WILLEBRAND'S DISEASE

286.52 ACQUIRED HEMOPHILIA

286.53 ANTIPHOSPHOLIPID ANTIBODY WITH HEMORRHAGIC DISORDER

286.59 OTHER HEMORRHAGIC DISORDER DUE TO INTRINSIC CIRCULATING ANTICOAGULANTS, ANTIBODIES, OR INHIBITORS

286.7 ACQUIRED COAGULATION FACTOR DEFICIENCY

 

 

Documentation Requirements

 

• Medical record documentation maintained in the patient’s file must document the condition for which the blood clotting factor is being given.

• In addition, the name of the factor and the dosage required and/or given must be included in the records. This information is normally found in the office/progress notes, pharmacy forms, hospital records, and/or treatment notes.

 

 

Treatment Logic

 

• Hemophilia is a hereditary blood disease characterized by greatly prolonged coagulation time.

• The blood fails to clot and abnormal bleeding occurs.

• It is a sex-linked hereditary trait transmitted by normal heterozygous females who carry the recessive gene.

• It occurs almost exclusively in males.

• For purposes of Medicare coverage, hemophilia encompasses Factor VIII deficiency (classic hemophilia, hemophilia A), Factor IX deficiency (hemophilia B, Christmas disease, plasma thromboplastin component), and von Willebrand’s disease.

• Approximately 80% of those with hemophilia have type A and both are associated with recurrent, spontaneous, and traumatic hemarthrosis.

• The frequency and severity of hemorrhagic events induced by hemophilia are related to the amount of coagulation factor in the blood.

• Those with mild hemophilia (defined as having from 5% to 40% of normal coagulation factor activity) experience complications only after having undergone surgery or experiencing a major physical trauma.

• Those with moderate hemophilia (from 1% to 5% of coagulation factor activity) experience some spontaneous hemorrhage but normally exhibit bleeding provoked by trauma. Those with severe hemophilia (less than 1% of coagulation factor activity) exhibit spontaneous hemarthrosis and bleeding.

• Treatment for these patients is dependent on the severity of the disease and may include the administration of blood clotting factors such as Factor VIII, Factor IX, Factor VIIa and, Anti-inhibitors to control the bleeding.

 

 

Sources of Information and Basis for Decision

 

FCSO LCD 29187, Hemophilia Clotting Factors, 01/01/2012. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Goldman: Cecil Textbook of Medicine (2004). Hereditary coagulation deficiencies (pp. 1069-75) W. B. Saunders This source used to gain textbook knowledge of hemophilia and the physiological implications of the disease.

 

Roberts HR, Monroe DM, Escobar, MA: Current Concepts of Hemostasis. Anesthesiology 2004 100:722-30. This source used to provide information about the role of blood clotting factors in hemostasis.

 

Shapiro, A. Inhibitor treatment: State of the art. Disease-A-Month 2003 49 This source provides information on the efficacy of the administration of blood clotting factors to assist in preventing and reducing bleeding episodes.

 

 

AMA CPT / ADA CDT 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. 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.

 

 

CMS LCD L29187 HEMOPHILIA CLOTTING FACTORS