LCD/NCD MedicationsL29226-LCD

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Automated World Health

Local Coverage Determination (LCD) for Metastron C Strontium-89 Chloride (L29226)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29226

LCD Title Metastron C Strontium-89 Chloride

Contractor's Determination Number A9600

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. 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 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 03/19/2009

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Metastron (A9600) is a therapeutic radiopharmaceutical and is a covered drug when used to radiate documented skeletal metastasis by intravenous injection for relief of pain. This treatment is rendered by a physician appropriately licensed to possess and administer therapeutic radioactive materials.

Metastron has been found to be highly effective in long term palliative treatment of pain resulting from skeletal metastases only. Payment may be made for this drug if:

• skeletal metastases are documented by radiology report or biopsy.

• it was injected on or after the FDA-approved date.

• it is reasonable and necessary for the individual patient.

Repeated administration of Metastron should be based on an individual patient's response to therapy, current symptoms and hematologic status and is not recommended at intervals of less than 90 days.

Use of Metastron in patients with evidence of seriously compromised bone marrow from previous therapy or disease infiltration is not recommended unless the potential benefit of the treatment outweighs its risks.

In view of delayed onset of pain relief, typically 7 to 20 days post-injection, administration of Metastron to patients with very short life expectancy is not usually recommended.

Administration of Metastron may be adjunct to any combination or single use of radiation therapy, chemotherapy and/or hormone therapy.

Metastron is not indicated in patients with cancer not involving the bone and should be used with caution in patients with platelet counts below 60,000 mm3 and white cell counts below 2,400 mm3.

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.

999x Not Applicable

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.

99999 Not Applicable

CPT/HCPCS Codes

77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION (INCLUDES 3-MONTH FOLLOW-UP CARE) A9600 STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE

ICD-9 Codes that Support Medical Necessity

This ICD-9-CM code only applies to HCPCS code A9600

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements N/A

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision Amersham International

Dorland's

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 03/01/2009

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:03/01/2009 Revised Effective Date: 03/19/2009

LCR B2009-053

April 2009 Update

Explanation of Revision: LCD revised to add statement that ICD-9-CM code 198.5 applies only to CPT/HCPCS code A9600. The effective date of this revision is based on process date.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL LCR B2009-045PR/VI

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29226) replaces LCD L5936 as the policy in notice. This document (L29226) is effective on 02/02/2009.

Reason for Change