R6 (effective date 11/01/2011): Correction to policy to remove the asterisk (*) from V42.0 and asterisked statement: *According to the ICD-9-CM, diagnosis code V42.0 is a secondary diagnosis code and should not be billed as a primary diagnosis. No notice given and none required.

R10 (effective 11/01/2011): Article for Intra-fraction Localization and Tracking of Target or Patient Motion During Delivery of Radiation Therapy (e.g., 3D Positional Tracking, Gating, 3D Surface Tracking), Each Fraction of Treatment (0197T) (A51453) has been added. Minor changes were made to reflect current template language. No comment period required and none given.

R13 (effective 11/01/2011): Due to the annual ICD-9-CM code update for 2012, ICD-9-CM codes 444.01 and 444.09 were added to the "ICD-9-CM Codes that Support Medical Necessity" section for CT Abdomen and Pelvis (CPT codes 72192, 72193, 72194, 74150, 74160, 74170, 74176, 74177, 74178, 76376 and 76377). The ICD-9-CM codes will be considered covered retroactive to October 1, 2011.

ICD-9-CM code 718.60 was deleted from the "ICD-9-CM Codes that Support Medical Necessity" section for CT Lower Extremity (CPT codes 73700, 73701, 73702, 76376 and 76377). No replacement code was issued. The coding change, a result of the annual ICD-9-CM code update for 2012 was inadvertently omitted from the "Revision History Explanation" for R12.

No comment and notice periods required and none given.

Article published 11/01/2011: The following indications have been added to the "Indications" section of the article for Prolia®:

• Effective 09/16/2011, the FDA approved denosumab (Prolia®) as a treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer. In these patients Prolia® also reduced the incidence of vertebral fractures.

• Prolia® is also indicated as a treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer.

R17 (effective 11/01/2011): A reconsideration was requested for the addition of language that would allow coverage and reimbursement for the administration of intravenous preparations of already available oral antiemetics under certain circumstances. Based on this reconsideration, the following sources have been added to the "Sources of Information" section of the LCD:

• Jacobsen PB, Bovbjerg DH, Redd WH. Anticipatory anxiety in women receiving chemotherapy for breast cancer. Health Psychology. 1993;12(6):469-475.
• Osoba D, Zee B, Pater J, Warr D, Latreille J, Kaizer L. Determinants of postchemotherapy nausea and vomiting in patients with cancer. J Clin Oncol. 1997;15(1):116-123.
• Petrella T, Clemons M, Joy A, Young S, Callaghan W, Dranitsaris G. Identifying patients at high risk for nausea and vomiting after chemotherapy: the development of a practical validated prediction tool. J Support Oncol. 2009;7(4):W1-W8.
• Shih V, Wan HS, Chan A. Clinical predictors of chemotherapy-induced nausea and vomiting in breast cancer patients receiving adjuvant doxorubicin and cyclophosphamide. Ann Pharmacother. 2009;43:444-452.
• Tsavaris N, Kosmas C, Mylonakis N, et al. Parameters that influence the outcome of nausea and emesis in cisplatin based chemotherapy. Anticancer Research. 2000;20:4777-4784.

In the "Limitations" section of the LCD the fourth paragraph has been revised to add the following language:
However, determinations as to whether medication is reasonable and necessary for an individual patient may be made on appeal on the same basis as all other such determinations (i.e., with support from the peer-reviewed literature, with the advice of medical consultants, with reference to accepted standards of medical practice, and in consideration of the medical circumstance of the individual case).

No comment and notice period required and none given.

R5 (published 11/01/2011): Annual LCD review performed October, 2011, per CMS Program Integrity Manual, Chapter 13, Section 13.4[C]. Content reviewed, and no changes required other than for minor formatting. No comment and notice periods required and none given.

Article published November 2011: Original version of article.

The original version of the corresponding LCD became effective on 12/01/2007.

Article published November 2011: The following indication for bladder carcinoma has been added to the "Indications" section of the article:

• Bladder carcinoma - recurrent or persistent disease (cytology positive, imaging and cystoscopy negative) after initial intravesical treatment for Tis or clinical stage Ta or T1 tumors and incomplete response to BCG and recurrent Tis or clinical stage Ta disease following intravesical treatment with BCG (no more than 2 consecutive treatments)

ICD-9-CM code V10.51 has been added to the "ICD-9 Codes that are Covered" section of the article effective for dates of service on or after 11/01/2011.

The following paragraph has been added to the "Coding Guidelines" section of the article:

R5 (effective 11/01/2011): Based on a provider request, ICD-9-CM code 785.6 was added to the "ICD-9-CM Codes that Support Medical Necessity" section for CPT code 76881 and 76882 with an effective date of November 1, 2011.

Minor template changes were made to reflect current template language. No comment and notice periods required and none given.

R6 (published 11/01/2011): ICD-9 code 379.27 has been added to payable ICD-9 codes for fluorescein angiography, effective for dates of service on or after 10/01/2011. No comment and notice periods required and none given.

R12 (effective 11/01/2011): For CPT code 97532, the Indications section was updated to add Clinical Psychologists as covered practitioners for this service. No comment or notice periods required and none given.

R8 (effective 11/01/2011): Based on a reconsideration, "Accreditation Commission for Health Care, Inc." has been added to the following paragraph in the "Other Comments" section of the LCD.

The first sentence of the "Abstract" has been revised to include the language "of recording" as shown below:

The following source has been added to the "Sources of Information and Basis for Decision" section of the LCD:

Minor changes were made to reflect current template language. No notice required and none given.

R5 (effective November 1, 2011): ICD-9-CM diagnosis code 379.27 was added to the coding list for CPT code 92134 for claims submitted on, or after, October 1, 2011. No notice given and none required.

R4 (effective 11/01/2011): ICD-9 codes 202.70-202.78 are added to the ICD-9 coding list for allogeneic hematopoietic stem cell transplantation (CPT code 38240) for all claims submitted on or after 10/01/2011. No notice given and none required.

Typographical correction to revision history for Revision 3 effective 10/01/2011 to add ICD-9-CM codes 200.40, 200.41, 200.42, 200.43, 200.44, 200.45, 200.46, 200.47, and 200.48 that were inadvertently omitted.

10/17/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00160 and 00332 are removed from this LCD. Effective on this date, claims processing for Kentucky –Part A and Ohio –Part A is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for these states.

R4 (effective 11/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section 13.4[C]. The entire policy was reviewed: The "CMS National Coverage Policy" section and references throughout the text have been updated to reflect the CMS Online Manual System. A number of minor changes are made to reflect the current CMS and National Government Services current policy formats.

Article published November 2011: Annual review per CMS Program Integrity Manual, Chapter 13, Section 13.4[C]. Content reviewed. Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines updated. Coding guidelines updated for current NGS template language.

October 2011 Revisions:

Effective on October 17, 2011, in accordance with Section 911 of the Medicare Modernization Act of 2003, claims processing for Kentucky and Ohio, Part A will be performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for these states. Accordingly, as of that date, fiscal intermediary numbers 00160 and 00332 are being removed from all NGS LCDs and articles.

10/03/2011 - corrected typo to remove 999.41 and 999.42 for CPT code 95180. These were not removed after automatically being inserted by FU contractor into coding list.

Typographical error corrected. ICD-9-CM code 171.0 was removed from the coding list in error with the 10/01/2011 code update and has been replaced. 

10/17/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, intermediary numbers 00160 and 00332 are removed from this article. Effective on this date, claims processing for Kentucky - Part A and Ohio -Part A is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for these states.

As a result of this transition, Kentucky and Ohio were removed from the paragraph for "Beneficiaries residing or receiving care in [our] jurisdiction" section of the article.

R6 (effective 10/17/2011): The appendices for Kentucky (A46215) and Ohio (A6223) have been removed from the "Related Document" section of the LCD. This is in accordance with Section 911 of the Medicare Modernization Act of 2003. Effective on 10/17/2011, claims processing for Kentucky and Ohio is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for these states. Minor changes were made to reflect current template language. No comment and notice periods required and none given.

10/17/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article has been retired for National Government Services. Effective on this date, claims processing for Kentucky is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for this state.

10/17/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article has been retired for National Government Services. Effective on this date, claims processing for Ohio is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for this state.

10/17/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article has been retired for National Government Services. Effective on this date, claims processing for Kentucky is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for this state.

Article for Self-Administered Drug Exclusion List - Medical Policy Article (R16) (A2313)

10/17/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article has been retired for National Government Services. Effective on this date, claims processing for Ohio is performed by CGS Administrators, LLC, the Part A/Part B MAC contractor for this state.