L29255

 

PEMETREXED

 

11/23/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Pemetrexed is FDA approved for treatment of the following medical conditions:

• Adjuvant treatment of malignant pleural mesothelioma (MPM) in combination with cisplastin for the treatment of patients whose disease is unresectable or who are otherwise not candidates for curative surgery.

• Single agent for the treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) after prior chemotherapy.

• Use in combination with cisplatin therapy for the initial treatment of patients with locally advanced or metastic non-squamous NSCLC.

• Maintenance treatment of advanced or metastatic nonsquamous NSCLC after first-line treatment with platinum-base chemotherapy (effective 07/09).

Pemetrexed is approved for the following off-label (non FDA-approved) medical condition:

• Thymic malignancies when used as a second line chemotherapy regimen.

• Second-line therapy as a single agent for local/regional recurrent or distant metastatic cervical cancer.

• Single-agent recurrence therapy if:

o Platinum resistant, for ovarian cancer that is recurrent after prior chemotherapy.

o Progressive, stable, or persistent on primary chemotherapy.

o  Relapse has occurred after complete remission following primary chemotherapy.

o Stage II-IV disease has shown partial response to primary treatment.

• Second-line therapy as a single agent for metastatic bladder cancer.

 

CPT/HCPCS Codes

 

 

J9305 INJECTION, PEMETREXED, 10 MG

 

 

ICD-9 Codes that Support Medical Necessity

 

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

163.0 MALIGNANT NEOPLASM OF PARIETAL PLEURA

163.1 MALIGNANT NEOPLASM OF VISCERAL PLEURA

163.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA

163.9 MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED

164.0 MALIGNANT NEOPLASM OF THYMUS

180.0 MALIGNANT NEOPLASM OF ENDOCERVIX

180.1 MALIGNANT NEOPLASM OF EXOCERVIX

180.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX

180.9 MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE

183.0 MALIGNANT NEOPLASM OF OVARY

183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE

183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS

183.4 MALIGNANT NEOPLASM OF PARAMETRIUM

183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS

183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA

183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE

188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER

188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER

188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER

188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER

188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER

188.5 MALIGNANT NEOPLASM OF BLADDER NECK

188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE

188.7 MALIGNANT NEOPLASM OF URACHUS

188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER

188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED

189.1 MALIGNANT NEOPLASM OF RENAL PELVIS

189.2 MALIGNANT NEOPLASM OF URETER

212.6 BENIGN NEOPLASM OF THYMUS

233.7 CARCINOMA IN SITU OF BLADDER

 

 

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 shall include the histologic type of cancer, stage, 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

• Pemetrexed is an antifolate containing the pyrrolopyrimidine-based nucleus that exerts antineoplastic activity by disrupting folate-dependent metabolic processes essential for replications.

 

Sources of Information and Basis for Decision

 

Clinical Pharmacology (2009) retrieved from http://www.clinicalpharmacology.com

 

FCSO LCD 29255, Pemetrexed,11/23/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

NCCN Clinical Practice Guidelines in Oncology™ V.2.2009. Thymic Malignancies retrieved from www.nccn.org on September 20, 2009.

 

The United States Pharmacopeia Drug Information (USP DI). 2006. Thomson Micromedex Health Care Series [on-line]. Available http://www.thomsonhc.com/

 

U.S. Food and Drug Administration, Department of Health and Human Services, CDER web site updates, February 2007. Available http://www.fda.gov/CDER/drug/infopage/alimta/default.htm

 

Facts & Comparisons 4.0 (2007) retrieved 08/16/2007 from http://online.factsand comparisons.com

 

 

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.

 

© Automated Clinical Guidelines, LLC 2011-2013

 

CMS LCD PEMETREXED