L29249-LCD

Automated World Health

Local Coverage Determination (LCD) for Paclitaxel (Taxol®) (L29249)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29249

LCD Title

Paclitaxel (Taxol®)

Contractor's Determination Number J9265

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

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

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, Chapter 15, Section 50

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40

CMS Manual System, Pub. 100-08, Medicare Program Integrity, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity Paclitaxel (Taxol®)-J9265

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.

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

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

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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.

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.

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 (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 2007.

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 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:02/02/2009

LCR B2009-

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 (L29249) replaces LCD L25074 as the policy in notice. This document (L29249) is effective on 02/02/2009.

Reason for Change