LCD/NCD Portal

L29309

 

VITAMIN B 12 INJECTIONS

 

04/06/2010

 

Indications and Limitations of Coverage and/or Medical Necessity

• Vitamin B 12 administration by injection is a covered benefit accepted as medically necessary when

o the beneficiary has a history of a low serum B 12 or

o Conditions causing or caused by a low serum B 12.

• In addition, vitamin B 12 will be considered medically necessary when

o administered as an adjunct to Alimta® or Folotyn™ treatment as follows:

o For Alimta® patients, patients must receive one intramuscular injection of vitamin B 12 during the week preceding the first dose of Alimta® and every three cycles thereafter

o For Folotyn™ patients, supplement patients with vitamin B 12 1 mg intramuscularly no more than 10 weeks prior to the first dose of Folotyn™, and every 8-10 weeks thereafter

o Subsequent vitamin B 12 injections may be given the same day as either Alimta® or Folotyn™

• Vitamin B 12 injections (J3420) used to strengthen tendons, ligaments, etc. of the foot are considered investigational and are therefore noncovered.

 

CPT/HCPCS Codes

 

 

J3420 INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG

 

 

ICD-9 Codes that Support Medical Necessity

 

 

260 KWASHIORKOR

261 NUTRITIONAL MARASMUS

263.1 MALNUTRITION OF MILD DEGREE

263.2 ARRESTED DEVELOPMENT FOLLOWING PROTEIN-CALORIE MALNUTRITION

263.8 OTHER PROTEIN-CALORIE MALNUTRITION

263.9 UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

266.2 OTHER B-COMPLEX DEFICIENCIES

281.0 PERNICIOUS ANEMIA

281.1 OTHER VITAMIN B12 DEFICIENCY ANEMIA

281.2 FOLATE-DEFICIENCY ANEMIA

281.3 OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED

281.9 UNSPECIFIED DEFICIENCY ANEMIA

336.2 SUBACUTE COMBINED DEGENERATION OF SPINAL CORD IN DISEASES CLASSIFIED ELSEWHERE

535.10 ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE)

564.2 POSTGASTRIC SURGERY SYNDROMES

577.1 CHRONIC PANCREATITIS

579.0 CELIAC DISEASE

579.1 TROPICAL SPRUE

579.2 BLIND LOOP SYNDROME

579.3 OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.4 PANCREATIC STEATORRHEA

579.8 OTHER SPECIFIED INTESTINAL MALABSORPTION

579.9 UNSPECIFIED INTESTINAL MALABSORPTION

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

 

 

Documentation Requirements

• Progress notes and laboratory test results indicating present or past values of serum B 12 as well as supporting the treatment for the identified diagnosis (es) need to be maintained and made available upon request in the event post-payment review is required. A serum B 12 level is not required if vitamin B 12 is administered in conjunction with Alimta® or Folotyn™.

• The medical record should reflect the patient is being treated with Alimta® or Folotyn™.

 

Treatment Logic

• Vitamin B 12 is essential for the formation of red blood cells and is used in the treatment of diseases in which there is defective red cell formation.

 

Sources of Information and Basis for Decision

 

Allos Therapeutics. (2009)Folotyn™ prescribing information.

 

Eli Lilly and Company. (2004). Prescribing information. This document was utilized to determine the indications and limitations of coverage associated with Alimta®.

 

Taber's Cyclopedic Medical Dictionary

 

04/06/2010

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 L29309 Vitamin B 12 Injections