TrailBlazer Revises Drugs & Biologicals LCDs

Health care providers in Colorado, New Mexico, Oklahoma and Texas submitting claims to TrailBlazer Health Enterprises should be aware of revisions the jurisdiction 4 (J4) Part A and Part B Medicare Administrative Contractor (A/B MAC) made, Oct. 5, to two local coverage determinations (LCD).

The revisions were made in response to a recent addition to the list of HCPCS Level II codes payable by Medicare, as noted in the October 2009 quarterly update released Aug. 28 by the Centers for Medicare & Medicaid Services (CMS).

Drugs and Biologicals – Chemotherapeutic 4I-92AB LCD

Existing HCPCS level II code J9035 Injection, bevacizumab, 10 mg will remain effective and is used to appropriately describe larger doses of bevacizumab (Avastin®). The following ICD-9-CM diagnosis codes for ocular conditions, however, were removed (effective Oct. 1) from the limited coverage section for J9035 in the Drugs and Biologicals – Chemotherapeutic 4I-92AB LCD:

• 362.07  Diabetic macular edema
• 362.35-362.36  Retinal vascular occlusion
• 362.52  Exudative senile macular degeneration of retina
• 365.63  Glaucoma associated with vascular disorders of eye

Additionally, based on changes in the Compendia, diagnosis codes 189.1 Malignant neoplasm of kidney and other unspecified organs and 199.1 Other malignant neoplasm without specification of site were added to the limited coverage section for J9201 Injection, gemcitabine hydrochloride, 200 mg; and diagnosis codes 205.00-205.02 Acute myeloid leukemia were added to the limited coverage for J0894 Injection, decitabine, 1 mg, effective Sept. 30.

Drugs and Biologicals – Non-Chemotherapeutic 4I-81AB LCD

The Drugs and Biologicals – Non-Chemotherapeutic 4I-81AB LCD adds new HCPCS Level II code Q2024 Injection, bevacizumab, 0.25 mg to the list of covered CPT®/HCPCS codes. Q2024 is used to appropriately describe smaller doses that total less than 10 mg of bevacizumab (Avastin®) per administration.

In addition to the aforementioned diagnosis codes moved from the Drugs and Biologicals – Chemotherapeutic 4I-92AB LCD, coverage for Q2024 is expanded to include the following diagnosis codes, effective Oct. 1:

• 362.02  Proliferative diabetic retinopathy
• 362.53  Cystad macular degeneration of retina
• 362.60-362.66  Peripheral retinal degenerations
• 364.42  Rubeosis iridis

Another addition to the covered CPT®/HCPCS codes list in the Drugs and Biologicals – Non-Chemotherapeutic 4I-81AB LCD is the instruction to use J3490 Unclassified drug to identify Injection, ferumoxytol (Feraheme™), 1.0 mg.

Medicare is establishing dual diagnosis limited coverage for J3490 when used to identify ferumoxytol.

Covered for primary diagnoses:

• 280.0-280.01 Iron deficiency anemias
• 280.9  Iron deficiency anemia, unspecified

Codes 280.0-280.1 and 280.9 as the primary diagnosis require a secondary diagnosis. Use 585.6 End stage renal disease as a secondary diagnosis code to indicate iron-deficiency anemia in end state renal disease (ESRD) patients undergoing hemodialysis.

Finally, J3420 Injection, vitamin B12 cyancocabalamin, up to 1,000 mcg has been removed from this LCD, and is being added to the SAD list, effective Oct. 12.

For more information, refer to Drugs and Biologicals – Chemotherapeutic 4I-92AB or Drugs and Biologicals – Non-Chemotherapeutic 4I-81AB LCD on the TrailBlazer Web site.

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