LCD Reference Article Article

Off-Label Use of Drugs and Biologicals for Anti-Cancer Chemotherapeutic Regimen

A58113

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Source Article ID
N/A
Article ID
A58113
Original ICD-9 Article ID
Not Applicable
Article Title
Off-Label Use of Drugs and Biologicals for Anti-Cancer Chemotherapeutic Regimen
Article Type
Article
Original Effective Date
06/08/2020
Revision Effective Date
11/16/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

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Article Text

Off-label (unlabeled) drug is defined as a use for a non-FDA approved indication that is not listed on the drug's official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration, and frequency of administration, and population to whom the drug would be administered.

Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given.

The general utilization of any cancer chemotherapy drug or biological will be covered for use that is not FDA approved (unlabeled) if used for anti-neoplastic conditions, and if the use is listed as acceptable in one of the Medicare-approved drug compendia and the use is not listed as "not indicated" or unfavorably evaluated in any of the compendia per CMS Internet-Only Manual (IOM), Pub 100-02, Chapter 15, 50.4.5 Off Label Use of Anti-Cancer Drugs and Biologicals.

Although NCCN Category 2B is not included in the IOM, NCCN 2B indications are supported by evidence and require a consensus of the NCCN expert panel. For this reason, CGS Administrators considers any off label/drug or biological with a NCCN Category 2B indication to meet the benefit category requirements.

CGS Administrators may also identify off-label uses for Anti-Cancer Drugs and Biologicals as part of anti-cancer chemotherapeutic regimen that are not listed as supported/recommended in medically accepted compendia (NCCN, Micromedex Drug DEX, Lexi-Drugs, AHFS or Clinical Pharmacology). Coverage will be determined for off-label use if supported by clinical research under the conditions identified in CMS Internet-Only Manual, Pub 100-02, Chapter 15, Section 50.4.5 Off-Label Use of Anti-Cancer Drugs and Biologicals. For a review of medications under ths process, please submit full articles, not abstracts, for consideration. CGS will communicate our decisions for off-label uses for Anti-Cancer Drugs and Biologicals an article published on our website.

Consistent with CMS Internet-Only Manual, Pub 100-02, Chapter 15, Section 50.4.5 D if a cancer chemotherapy drug /biologic use is identified as not indicated by the Centers for Medicare and Medicaid Services (CMS) or the FDA, or use is specifically identified as not indicated in one or more of the compendia listed in Pub 100-02, Chapter 15, Section 50.4.5 B, or if CGS determines that peer-reviewed medical literature does not support the off-label usage, the drug/biologic is not covered.

List the appropriate J or Q to indicate the drug name. When a specific HCPCS code does not exist, list the appropriate NOC code J3490, J3590, or J9999 with the drug name, and dose in the remarks field of the claim Item 19 of the CMS-1500 form for claims billed to the Part B MAC.

For Part A, claims with C9399 are suspended, and remarks should be placed on the claim in field locator 80 for the UB04 claim form or SV202-7 for 837I electronic claim.

Facilities under the hospital OPPS may use code C9399, billed as one unit, if it does not have an assigned HCPCS or the assigned HCPCS is not yet effective.

Note: Claims billed to the Part B MAC with C9399 will be rejected.

Claims billed with a NOC drug code are suspended and the following should be provided on the claim in the following fields:

  • Field locator 80 for paper claims /line SV202-7 for electronic claims for Part A.
  • Box 19 for paper claims/loop 2400 or SV101-7 for Part B.

Claims billed for Not Otherwise Classified (NOC) codes need to include the following information in the fields listed above:

  • Name of the drug
  • Dose administered (mg, cc, etc.)
  • Route of administration (IV, IM, SC, PO, etc.)
  • NDC number if available
  • The invoice price (for new drugs if the wholesale acquisition cost (WAC) is unavailable, or for compounded drugs).

The JW modifier is required for wastage in single-dose vials; this modifier does not apply to multi-dose vials per CMS Internet-Only Manual, Pub 100-04, Chapter 17, Section 40 Discarded Drugs and Biologicals (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf).

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Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/16/2023 R2

R2

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

01/01/2022 R1

R1

Revison Effective 01/01/2022

Revision Explanation: Reviewed article and updated text to clarify information needed for a review for those drugs not listed as supported/recommended in accepted compendia.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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Public Versions
Updated On Effective Dates Status
11/07/2023 11/16/2023 - N/A Currently in Effect You are here
01/13/2022 01/01/2022 - 11/15/2023 Superseded View
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