LCD/NCD Portal

L29226

 

METASTRON C STRONTIUM-89 CHLORIDE

 

 

03/19/2009

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• 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:

o Skeletal metastases are documented by radiology report or biopsy.

o It was injected on or after the FDA-approved date.

o 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.

 

 

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

 

 

Treatment Logic

 

• 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.

 

 

Sources of Information and Basis for Decision

 

Amersham International

 

Dorland's

 

03/19/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

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 L29226 METASTRON C STRONTIUM-89 CHLORIDE