Automated World Health
L32493
BENDAMUSTINE HYDROCHLORIDE (TREANDA®)
06/12/2012
Indications and Limitations of Coverage and/or Medical Necessity
Bendamustine is approved by the Food and Drug Administration (FDA) for injection for the treatment of patients with the following indications:
• Chronic lymphocytic leukemia (CLL).
o Efficacy relative to first line therapies other than chlorambucil has not been established.
• Indolent B-cell non-Hodgkin’s lymphoma (NHL) that has progressed during or within six months of treatment with rituximab or a rituximab-containing regimen.
Medicare will consider the use of bendamustine hydrochloride (Treanda®) as medically reasonable and necessary for the FDA approved uses as well as the following off-labeled indications per the National Comprehensive Cancer Network (NCCN):
• Hodgkin Lymphoma- Classical Hodgkin lymphoma
o Second-line or salvage therapy as a single agent
prior to autologous stem cell rescue for progressive disease
• with radiation therapy (RT)
• without radiation therapy (RT)
For relapsed disease in patients initially treated with chemotherapy.
• with radiation therapy (RT)
• without radiation therapy (RT)
• Hodgkin Lymphoma- Lymphocyte predominant Hodgkin lymphoma
o Second-line or salvage therapy as a single agent or in combination with rituximab
with or
without RT prior to autologous stem cell rescue for progressive disease or
for relapsed disease in patients initially treated with chemotherapy
with or
Without RT.
• Multiple myeloma
o Salvage therapy on or off clinical trials as a single agent for:
disease relapse or
For progressive or refractory disease.
• Waldenström’s macroglobulinemia/Lymphoplasmacytic lymphoma
o Used with or without rituximab as:
Primary therapy.
salvage therapy for disease that does not respond to primary therapy or
For progressive or relapsed disease.
CPT/HCPCS Codes
J9033 INJECTION, BENDAMUSTINE HCL, 1 MG
ICD-9 Codes that Support Medical Necessity
200.00 RETICULOSARCOMA UNSPECIFIED SITE
200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.07 RETICULOSARCOMA INVOLVING SPLEEN
200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.10 LYMPHOSARCOMA UNSPECIFIED SITE
200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.17 LYMPHOSARCOMA INVOLVING SPLEEN
200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE
200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN
200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK
200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES
200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES
200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES
200.37 MARGINAL ZONE LYMPHOMA, SPLEEN
200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.47 MANTLE CELL LYMPHOMA, SPLEEN
200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES
200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES
200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN
200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN
200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.77 LARGE CELL LYMPHOMA, SPLEEN
200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE
200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN
200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.40 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE
201.41 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.42 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES
201.43 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.44 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.45 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.46 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES
201.47 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN
201.48 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES
201.50 HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE
201.51 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.52 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES
201.53 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.54 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.55 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.56 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES
201.57 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN
201.58 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
201.60 HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE
201.61 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.62 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES
201.63 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.64 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.65 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.66 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES
201.67 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN
201.68 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES
201.70 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE
201.71 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.72 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES
201.73 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.74 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.75 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.76 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES
201.77 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN
201.78 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES
201.90 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE
201.91 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.92 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES
201.93 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.94 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.95 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.96 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES
201.97 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN
201.98 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 NODULAR LYMPHOMA UNSPECIFIED SITE
202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
202.07 NODULAR LYMPHOMA INVOLVING SPLEEN
202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE
202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES
202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES
202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN
202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20 SEZARY'S DISEASE UNSPECIFIED SITE
202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.27 SEZARY'S DISEASE INVOLVING SPLEEN
202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE
202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN
202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE
202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN
202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE
202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN
202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE
202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES
202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES
202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN
202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN
202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES
202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES
202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN
202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE
202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES
202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES
202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN
202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.02 MULTIPLE MYELOMA, IN RELAPSE
203.10 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.12 PLASMA CELL LEUKEMIA, IN RELAPSE
203.80 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION
204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE
238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS
273.3 MACROGLOBULINEMIA
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 documenting the clinical indications for which these drugs are being used.
o The documentation usually indicates the type of cancer, 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 ordering/referring physician must state the clinical indication/medical need for using the chemotherapy drug in the order.
Treatment Logic
• Bendamustine hydrochloride (Treanda®) is a bifunctional mechlorethamine derivative with alkylator and antimetabolite activities.
• The exact mechanism of action remains unknown, however, bendmustine hydrochloride appears to act primarily as an alkylator.
• It is believed to inhibit DNA, RNA and protein synthesis and subsequently apoptosis.
Sources of Information and Basis for Decision
Clinical Pharmacology (www.clinicalpharmacology.com) November 2011.
Knauf, W., Lissichkov, T., Aldaoud, A., Liberati, A., Loscertales, J., Herbrecht, R., Juliusson, G., Postner, G., Gercheva, L., Goranov, S., Becker, M., Fricke, H., Huguet, F., Giudice, I., Klein, P., Tremmel, L., Merkle, K., Montillo, M., (2009). Phase III randomized study of bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukemia. Journal of Clinical Oncolocy, 27, (26), 4378-4384. doi: 10.1200/JCO.2008.20.8389
LCDs or policies from other Medicare contractors and Private Insurers
National Comprehensive Cancer Network (2011). Non-hodgkin’s lymphomas. NCCN clinical practice guidelines in oncology-V.4.2011. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/nhl.pdf
NCCN Drug Compendium (www.nccn.org), January 2012.
U.S. Food and Drug Administration, Department of Health and Human Services, CDER web site updates, November 2011.
06/12/2012
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 BENDAMUSTINE HYDROCHLORIDE (TREANDA®)
CMS LCD BENDAMUSTINE HYDROCHLORIDE (TREANDA®)