Chemotherapy Drugs and their Adjuncts
L37205
Chemotherapy drugs and adjuncts are covered when medically necessary and either (1) FDA‑approved for the specific ICD‑10 diagnosis and listed in NCCN as Category 1 or 2A with use per NCCN Recommended Use, or (2) supported by specified Medicare‑approved compendia at accepted levels (DrugDex I/IIa/IIb; AHFS/Clinical Pharmacology 'supportive'; Lexi‑Drugs Off‑Label with evidence level A). Uses listed as not supportive/Category 3/Class III/unsupported in the compendia, uses inconsistent with NCCN Recommended Use, or when medical necessity/FDA/compendia support is lacking, are not covered. Documentation must include the specific ICD‑10 diagnosis linked to compendia or FDA approval, compendia citations or FDA evidence, and justification of dose and route.
"Chemotherapy agents are covered when medically necessary, the drug is FDA-approved for the indication, and the drug is listed in the NCCN Clinical Practice Guidelines for the specific ICD-10 diagno..."