Pinnacle Business Solutions, Inc as a Medicare carrier has determined that
the following anti-cancer drugs may be billed with the specified diagnosis codes
only, as of 07/15/2007. Guidelines for coverage of anti-cancer drugs include FDA
approval for specific indications and citation in the USPDI (United States
Pharmacopeia Drug Information) and/or AHFS (American Hospital Formulary Service
Drug Information) providing support for the drug. Text analysis determines the
support of a particular use. Please refer to the
Local Coverage Determination
AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications
and limitations of coverage and/or medical necessity as well as documentation
requirements.
As noted in policy AC-01-024,
clinical research appearing in peer reviewed medical literature is considered
for off-label indications not listed in the CMS approved compendia. Please
submit your request with copies of Phase III articles that meet the
guidelines outlined in the Indications and Limitations section B.4.c. of policy
AC-01-024 to the address listed below. In order to have valid request routed
correctly, please address both the request letter and the envelope to:
RN III Medical Review
Diagnosis Consideration Anti-Cancer Drug
PO BOX 1418
Little Rock AR 72203
This address is NOT to be used for individual claim re-review and
submitting your requests to this address will only delay your response time as
your request will be re-routed to the appropriate department.
This is notification that effective July 15, 2007, the following HCPCS codes
and associated ICD-9 codes will be placed on an active audit for verification of
appropriate drug/diagnosis. Claims for anti-cancer drugs billed without a
specified allowable diagnosis will be denied. Approved ICD-9 codes will be
updated to reflect changes in indications and approval as noted by the FDA, AFHS,
and/or USPDI.
In order to access the individual drug articles to view specific covered
ICD-9 to HCPCS code relationships, please view the
CMS Medicare Coverage Database Anti-Cancer Drug Article List
within the CMS Database for Key Articles.
