CMS expands coverage for three drug regimen to fight nausea during chemotherapy

Physician practices will soon be able to get paid for use of a three-drug antiemetic regimen used to prevent nausea and vomiting by patients receiving chemotherapy for an expanded list of chemotherapy drugs, under a National Coverage Determination recently posted by CMS. The change in coverage is effective retroactive to May 29, 2013, though MACs will have until July 7, 2014, to implement the change.

The three drug regimen – an oral aprepitant (J8501), an oral 5Ht3 antagonist (Q0166, Q0179, Q0180) and oral dexamethasone (J8540) – is already covered for nine chemotherapy agents. The NCD expands coverage to cases when the patient is receiving one of these 11 chemotherapy agents being added to the covered list:

• Alemtuzumab (J9010)
• Azacitidine (J9025)
• Bendamustine (J9033)
• Carboplatin (J9045)
• Clofarabine (J9027)
• Cytarabine (J9098, J9100, J9110)
• Daunorubicin (J9150, J9151)
• Idarubicin (J9211)
• Ifosfamide (J9208)
• Irinotecan (J9206)
• Oxaliplatin (J9263)

Individual MACs will have the discretion to determine coverage for any other oral three-drug regimens that may reduce nausea or vomiting with either the listed chemotherapy agents or others. Any new FDA-approved drug that meets the criteria for use with this three-drug regimen should be billed with unspecified code Q0181 until a specific code is assigned to the drug.

Any claims with dates of service of on or after May 29, 2013 that were denied may be resubmitted for payment. Use of oral aprepitant code J8501 or the not otherwise classified code Q0181 will be denied for services on or after May 29, 2013, if the diagnosis codes V58.11 or Z51.11 are not on the claim.

The three-drug regimen must be administered either immediately before or within 48 hours after anti-cancer chemotherapy and would replace a covered non self-administered drug.