C7B.09 — Secondary carcinoid tumors of other sites
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A written, signed, and dated order for the oral anticancer drug must be received by the supplier before submitting the claim.
- The ICD-10 diagnosis code describing the condition for which the drug is used must be included on each claim.
- Claims for J8498 or J8597 must identify the drug name, manufacturer, and dosage strength of each tablet/suppository and must indicate which oral anticancer drug is being used and the prescribed frequency in the narrative field of an electronic claim.
- Suppliers must use the NDC that matches the product dispensed and follow NCPDP/NDC billing instructions when submitting claims in NCPDP format.
Key Coverage Criteria
- An oral anticancer drug is covered only if it is an FDA-approved drug or biological and meets all other Medicare statutory/regulatory requirements.
- The oral drug must have the same active ingredient and the same chemical/generic name as a non-self-administrable anticancer drug or be a prodrug metabolized to the same active ingredient as the covered non-self-administerable form.
- The oral anticancer drug must be used for the same anticancer chemotherapeutic indications (including off-label uses) as the non-self-administerable form.
- The oral anticancer drug must be prescribed by a practitioner licensed under state law to prescribe anticancer chemotherapeutic agents and a written, signed, and dated order must be received by the supplier before claim submission.
- A self-administered antiemetic billed with HCPCS J8498 or J8597 is covered when it is used with a covered oral anticancer drug, is likely needed to prevent emesis from that anticancer drug, and is administered within 2 hours before the oral anticancer drug.
- An oral antiemetic drug is covered when it has been ordered by the treating practitioner as part of a cancer chemotherapy regimen.
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