LCD for Off-Label Coverage of FDA Approved Drugs and Biologicals (L13121)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L13121 

 

LCD Title 

Off-Label Coverage of FDA Approved Drugs and Biologicals 

 

Contractor's Determination Number 

L13121 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 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 National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

CMS Pub 100-2, 15, §50, 17-§10, Drugs and biologicals.

CMS Pub 100-2, 1 §30

CMS Pub 100-2, 16 §20

Program Integrity Manual (PIM), Section 2.3.2.1. Evidence supporting LMRP.

Program Integrity Manual (PIM), Section 2.3.2.3. Section addressing alternative services be tried first. 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/30/2003  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 01/01/2007  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

The Least You Need to Know


Riverbend will cover any FDA approved drug for both its labeled and off-label indications unless an off-label indication is specifically precluded in another LMRP.Riverbend will not cover Investigational New Drugs (IND). It will not cover investigational uses of established drugs except for chemotherapeutic agents used in a cancer center protocol for the treatment of a malignant disease.




The Off-label use of a drug is the use of drugs for an indication, dosage form, dose regimen, population or other use parameter not included as an indication on the drug’s label as approved by the FDA.

Medicare recognizes off-label use of FDA approved drugs. Medicare guidelines dictate that certain medical services, which are deemed reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, are covered services [SSA section 1862(a)(1)]. Coverage of off-label FDA approved drugs is determined taking into consideration the major drug compendia, authoritative medical literature and /or generally accepted medical practice in the community and as long as FDA has not specified such use as non-approved (CMS Pub 100-2, 1 §30) (MCM 2049).

This policy defines what may be covered by Medicare, outlines the requirements to consider off-label drug use and is not intended to restrict what providers may provide nor what patients may receive. Physicians who chooses to use a product for an indication not in the approved labeling have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product's use and effects.


Investigational New Drugs (IND) or Investigational Use of Marketed Drugs, Biologics and Medical Devices

The investigational use of approved, marketed products differs from” Off-Label Drug Use”. "Investigational use" suggests the use of an approved product in the context of a clinical study protocol [see 21 CFR 312.3(b)]or the use of a product for an indication that is not supported by the current body of medical literature.

Investigational New Drugs (IND) or investigational use of newly approved or established drugs is not covered by Medicare (CMS Pub 100-2, 1 §30). However, Riverbend does not generally consider the use of an established chemotherapeutic agent to be investigational when it is used under an established cancer center research protocol in the treatment of a malignancy for which it has not yet been approved unless that use is specified listed as I&E in another LMRP.




FDA-approved drugs used for indications other than those specified on the FDA-approved labeling drugs will be covered if:

 

  • The use is listed as “off-label use” in the USPDI.


FDA-approved drugs used for indications other than those specified on the FDA-Approved labeling <Imay be covered if:

 

  • The use is supported (at a possibly effective level or higher) in one or more citations in any of the following drug compendia AND the use is not listed as ”not indicated”:

 

    • American Hospital Formulary Service Drug Information (AHFS)
    • American Medical Association Drug Evaluations

 

  • A decision to support the use has been made by one of the above compendia and is forthcoming, with findings based upon reports in one of the following peer-reviewed medical journals. (This applies only when an unlabeled use does not appear in any of the compendia or is listed as insufficient or investigational):

 

    • American Journal of Medicine
    • Annals of Internal Medicine
    • The Journal of the American Medical Association
    • The Journal of Clinical Oncology
    • Blood
    • Journal of the National Cancer Institute
    • The New England Journal of Medicine
    • British Journal of Cancer
    • British Journal of Hematology
    • British Medical Journal
    • Cancer
    • Drugs
    • European Journal of Cancer
    • Lancet
    • Leukemia

 

  • It is determined by the contractor to be medically accepted generally as safe and effective for the particular use (MCM 2049).



Off-label uses of drugs used in an anti-cancer chemotherapeutic regimen are covered for a medically accepted indication as defined in CMS Pub 100-2, 15, §50.4-50.4.4.1, 100-4, 18-§10.2

Indications not listed as labeled or off-labeled in the USPDI may require hard copy documentation at the time of claim submission.


A drug is not covered if a use is identified as:

 

  • Not indicated by CMS or the FDA;
  • Not indicated in at least one of the two major compendia mentioned;
  • Not safe and effective, based on peer reviewed medical literature;
  • Not supported by any of above criteria and/or requirements



Other Comments

1. Determinations as to whether medication is reasonable and necessary for an individual patient should be made on the same basis as all other such determinations. [CMS Pub 100-2, 1 §30 guidelines in which medications would not be reasonable and necessary].

2. Peer reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies or abstracts (including meeting abstracts).

3. An ABN (Advance Beneficiary Notice) may be provided to the patient when the provider deems the services is not medically necessary or exceeds acceptable standard of medical practice as indicated in the label and off-label drug compendia.

 

 

Coverage Topic 

Prescription Drugs
 

 

Coding Information

Bill Type Codes: 

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

14x

Non-Patient Laboratory Specimens

18x

Hospital-swing beds

21x

SNF-inpatient, Part A

23x

SNF-outpatient (HHA-A also)

71x

Clinic-rural health

72x

Clinic-hospital based or independent renal dialysis facility

85x

Special facility or ASC surgery-rural primary care hospital (eff 10/94)

 

 

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

 

0636

Drugs requiring specific identification-detailed coding (eff 3/92)

 

 

CPT/HCPCS Codes 

 

J0120 - J8999

INJECTION, TETRACYCLINE, UP TO 250 MG - PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS

J9000 - J9999

DOXORUBICIN HCL, 10 MG - NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS

These codes were previously Not Otherwise Classified (NOC) codes. They have been moved to Field 24 (CPT/HCPCS Codes) on 10/9/2003.

J3490

UNCLASSIFIED DRUGS

 

 

ICD-9 Codes that Support Medical Necessity 

 

XX000

Not Applicable

 

 

Diagnoses that Support Medical Necessity 

Any ICD-9 code that describes a condition other than FDA approved indications will be subject to the requirements of this policy 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

1. Physicians or suppliers must submit copies of relevant supporting full-text articles or literatures when an unlabeled use does not appear in at least one of the two major compendia mentioned or is listed as insufficient data or investigational. Abstracts, case reports, opinions or book chapters are not acceptable.

2. Medical records must be available to Medicare upon request.

 

 

Appendices 

 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Other contractor’s Local Medical Review Policy (Empire, Palmetto GBA, BC Kansas)

"U.S. Food and Drug Administration", http://www.fda.gov/oc/ohrt/irbs/offlabel.html

Taber’s Cyclopedic Medical Dictionary

 

 

Advisory Committee Meeting Notes 

Public Open Meeting to discuss the draft policy was held 06/05/2003.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

05/02/2003 

 

End Date of Comment Period 

06/15/2003 

 

Start Date of Notice Period 

08/14/2003 

 

Revision History Number 

L13121a 

 

Revision History Explanation 

08/10/2004 Crosswalked references to Online Manual

11/07/2004 - The description for CPT/HCPCS code J0150 was changed in group 1
11/07/2004 - The description for CPT/HCPCS code J0152 was changed in group 1
11/07/2004 - The description for CPT/HCPCS code J1564 was changed in group 1
11/07/2004 - The description for CPT/HCPCS code J2324 was changed in group 1

11/07/2004 - CPT/HCPCS code J1562 was deleted from group 1
11/07/2004 - CPT/HCPCS code J2994 was deleted from group 1
11/07/2004 - CPT/HCPCS code J2996 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7610 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7615 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7620 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7625 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7627 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7630 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7640 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7645 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7650 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7651 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7652 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7653 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7654 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7655 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7660 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7665 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7670 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7672 was deleted from group 1
11/07/2004 - CPT/HCPCS code J7675 was deleted from group 1

01/29/2005 - CPT/HCPCS code J0151 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0286 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0340 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0400 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0510 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0590 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0635 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0695 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0730 was deleted from group 1
01/29/2005 - CPT/HCPCS code J0810 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1050 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1090 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1095 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1362 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1561 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1690 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1739 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1741 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1755 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1820 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1910 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1930 was deleted from group 1
01/29/2005 - CPT/HCPCS code J1970 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2000 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2240 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2330 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2350 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2352 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2480 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2500 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2512 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2640 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2860 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2915 was deleted from group 1
01/29/2005 - CPT/HCPCS code J2970 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3080 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3245 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3270 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3390 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3395 was deleted from group 1
01/29/2005 - CPT/HCPCS code J3450 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7315 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7316 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7508 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7618 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7619 was deleted from group 1
01/29/2005 - CPT/HCPCS code J7621 was deleted from group 1
01/29/2005 - CPT/HCPCS code J9180 was deleted from group 1

11/26/2005 - The description for CPT/HCPCS code J7340 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7342 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7343 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7344 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7350 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code J7626 was changed in group 1

11/26/2005 - CPT/HCPCS code J0880 was deleted from group 1
11/26/2005 - CPT/HCPCS code J1563 was deleted from group 1
11/26/2005 - CPT/HCPCS code J1564 was deleted from group 1
11/26/2005 - CPT/HCPCS code J1750 was deleted from group 1
11/26/2005 - CPT/HCPCS code J2324 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7051 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7317 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7320 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7616 was deleted from group 1
11/26/2005 - CPT/HCPCS code J7617 was deleted from group 1

This LCD was converted from an LMRP on 12/8/2005

7/2/2006 - The description for Bill code 14 was changed

11/18/2006 - The description for CPT/HCPCS code J0886 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7611 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7612 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7613 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7614 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7620 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7622 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7624 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7626 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7627 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7628 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7629 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7633 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7635 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7636 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7637 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7638 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7640 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7641 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7642 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7643 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7644 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7648 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7649 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7658 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7659 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7668 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7669 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7680 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7681 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7682 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7683 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J7684 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code J9264 was changed in group 1

11/18/2006 - CPT/HCPCS code J2912 was deleted from group 1
11/18/2006 - CPT/HCPCS code J7188 was deleted from group 1
11/18/2006 - CPT/HCPCS code J7317 was deleted from group 1
11/18/2006 - CPT/HCPCS code J7320 was deleted from group 1
11/18/2006 - CPT/HCPCS code J7350 was deleted from group 1

07/08/2007 - CPT/HCPCS code J7319 was deleted from group 1

11/10/2007 - The description for CPT/HCPCS code J0702 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J1562 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J1566 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J2545 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J3487 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J7187 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J7608 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J7631 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J7639 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code J9225 was changed in group 1

11/10/2007 - CPT/HCPCS code J1567 was deleted from group 1
11/10/2007 - CPT/HCPCS code J7345 was deleted from group 1
11/10/2007 - CPT/HCPCS code J7611 was deleted from group 1
11/10/2007 - CPT/HCPCS code J7612 was deleted from group 1
11/10/2007 - CPT/HCPCS code J7613 was deleted from group 1
11/10/2007 - CPT/HCPCS code J7614 was deleted from group 1

2/18/2008 - The description for Bill code 21 was changed

04/19/2008 - The description for CPT/HCPCS code J0220 was changed in group 1 

 

Reason for Change 

Other
 

Last Reviewed On Date 

05/14/2008 

 

Related Documents 

Article(s)
A37949 - Off-Label Coverage of FDA Approved Drugs and Biologicals

 

LCD Attachments 

FAQ - Comment and Response (7,020 bytes)

 

Other Versions 

Updated on 04/03/2008 with effective dates 01/01/2007 - N/A

Updated on 02/18/2008 with effective dates 01/01/2007 - N/A

Updated on 11/16/2007 with effective dates 01/01/2007 - N/A

Updated on 07/17/2007 with effective dates 01/01/2007 - N/A

Updated on 03/30/2007 with effective dates 01/01/2007 - N/A

Updated on 03/22/2007 with effective dates 01/01/2007 - N/A

Updated on 03/21/2007 with effective dates 01/01/2007 - N/A

Updated on 01/12/2007 with effective dates 01/01/2007 - N/A

Updated on 01/11/2007 with effective dates 12/09/2005 - 12/31/2006

Updated on 09/01/2006 with effective dates 12/09/2005 - N/A

Updated on 12/16/2005 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 01/01/2005 - 12/08/2005

Updated on 02/11/2005 with effective dates 01/01/2005 - N/A

Updated on 11/08/2004 with effective dates 11/07/2004 - 12/31/2004

Updated on 08/10/2004 with effective dates 09/30/2003 - 11/06/2004

Updated on 10/28/2003 with effective dates 09/30/2003 - N/A

Updated on 10/22/2003 with effective dates 09/30/2003 - N/A

Updated on 10/14/2003 with effective dates 09/30/2003 - N/A

Updated on 09/30/2003 with effective dates 09/30/2003 - N/A

Updated on 09/30/2003 with effective dates 09/30/2003 - N/A

Updated on 08/12/2003 with effective dates 09/28/2003 - N/A