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Medical Coding News Archives

Immunotherapy for Metastatic Prostate Cancer Now Covered

 
August 2, 2011:
A new therapy has been approved for payment by the Centers for Medicare and Medicaid Services that specifically targets castration-resistant, metastatic prostate cancer. New treatments for this type of cancer are particularly welcome since the median survival after diagnosis is usually less than two years.

Approved in 2010 by the Food and Drug Administration (FDA), sipuleucel-T (Provenge®) is the first immunotherapy for prostate cancer to receive FDA approval. Based on a review under the national coverage determination process, CMS has determined that treatment with sipuleucel-T; Provenge does improve health outcomes for men with this condition and is reasonable and necessary for this on-label indication. Sipuleucel-T has the added benefit of being less toxic than existing therapies.

Therefore, effective for services performed on or after June 30, 2011, benefits will be provided for this service when:

  • The patient has asymptomatic or minimally symptomatic metastatic castrate-resistant (hormone refractory) prostate cancer.
  • Treatment is limited to one treatment regimen in a patient’s lifetime.
  • Treatment comprises three doses with each dose administered approximately two weeks apart for a total treatment period not to exceed 30 weeks from the first administration.
  • When provided for the on-label indication of this type of prostate cancer, the service must be billed using ICD-9-CM code 185 (Malignant neoplasm of prostate) and at least one of the following ICD-9-CM codes that indicate metastatic spread of the disease: 196.1, 196.2, 196.5, 196.6, 196.8, 196.9, 197.0, 197.7, 198.0, 198.1, 198.5, 198.7, and 198.82.

Contractors have been instructed to continue to process claims for Provenge with dates of service on June 30, 2011, as they currently process not otherwise classified code J3590, J3490 or C9273. Code C9273 was deleted June 30, 2011, and replaced by Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion.

 

 
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