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The following is an excerpt from NGS policy (see link below for full
policy).
This policy is effective January 1, 2009 but will not be implemented
until March 1, 2009.
…not only does the indication for the use of the drug
need to meet medical necessity requirements, but the route of
administration is also subject to medical necessity criteria. Contractors
must continue to apply the policy that not only the drug is medically
reasonable and necessary for any individual claim, but also that the route
of administration is medically reasonable and necessary. That is, if a
drug is available in both oral and injectable forms, the injectable form
of the drug must be medically reasonable and necessary as compared to
using the oral form .(Pub 100-02, Medicare Benefit Policy Manual, Chapter
15, Section 50.2 - Determining Self-Administration of Drug or Biological
(Rev. 91; Issued: 06-20-08; Effective/Implementation Date: 07-21-08)). Medication
given by injection (parenterally) is not covered if standard medical
practice indicates that the administration of the medication by mouth
(orally) is effective and is an accepted or preferred method of
administration. (Pub 100-02, Medicare Benefit Policy Manual,
Chapter 15, Section 50.4.3) Specifically, for anti-emetic medication, CMS
states: It is recognized that a limited number of patients will fail on
oral anti-emetic drugs. Intravenous anti-emetics may be covered (subject
to the rules of medical necessity) when furnished to patients who fail on
oral anti-emetic therapy. (Pub 100-02, Medicare Benefit Policy Manual,
Chapter 15, Section 50.5.4)
Link to full policy:
http://www.ngsmedicare.com/NGSMedicare/lcd/L25820_active_lcd.htm
NYSSMOH
News Update
Re:
IV anti-emetics
As
of March 1, 2009, CMS will not cover any IV anti-emetic if an oral
formulation of the drug is available unless there is a medical
reason the patient must receive the IV rather than the oral form.
Palonosetron (Aloxi) given IV has been found to have superior efficacy
in several published studies. Although the FDA has approved oral
palonosetron, it is not available and has not even been manufactured. We
have been advised that in the absence of an available oral form, CMS
will cover IV palonosetron.
Please
note the use of palonosetron must be medically necessary and
documented in chart notes.
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