CPT CODE J3489, J9310, J9201


Group 1 Codes:

J3489 INJECTION, ZOLEDRONIC ACID, 1 MG

Coverage Indications, Limitations, and/or Medical Necessity


Indications

Zoledronic acid is indicated for the treatment of:

Acute Hypercalcemia of malignancy;

Multiple myeloma;

Bone metastases from solid tumors in conjunction with standard antineoplastic therapy, including bone metastases from multiple myeloma, breast carcinoma, prostate carcinoma, and other solid tumors. Note: Prostate cancer should have progressed after treatment with at least one hormonal therapy;

Drug-induced osteopenia, secondary to androgen-deprivation therapy in prostate cancer patients (prophylaxis);

Cancer treatment-induced bone loss in breast cancer;

Pagets disease;

Post-Menopausal (Senile) Osteoporosis;

Osteoporosis in men; and

Glucocorticoid - induced osteoporosis in patients expected to be on glucocorticoids for at least 12 months (Effective 3/13/2009).


Limitations

The safety and efficacy of zoledronic acid in the treatment of hypercalcemia associated with hyperparathyroidism or with other non-tumor-related conditions has not been established.

Osteonecrosis of the jaw has been reported. All patients should have a routine oral exam prior to treatment.



ICD-10 CODE DESCRIPTION

C00.0 - C43.9 - Opens in a new window Malignant neoplasm of external upper lip - Malignant melanoma of skin, unspecified

C4A.0 - C4A.9 - Opens in a new window Merkel cell carcinoma of lip - Merkel cell carcinoma, unspecified

C44.00 - C49.9 - Opens in a new window Unspecified malignant neoplasm of skin of lip - Malignant neoplasm of connective and
soft tissue, unspecified

C50.011 - C75.9 - Opens in a new window Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of
endocrine gland, unspecified

C7A.00 - C7B.8 - Opens in a new window Malignant carcinoid tumor of unspecified site - Other secondary neuroendocrine tumors

C76.0 - C79.9 - Opens in a new window Malignant neoplasm of head, face and neck - Secondary malignant neoplasm of
unspecified site
C80.0 - C84.79 - Opens in a new window Disseminated malignant neoplasm, unspecified - Anaplastic large cell lymphoma, ALK-
negative, extranodal and solid organ sites

C84.A0 - C84.Z9 - Opens in a new window Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell
lymphomas, extranodal and solid organ sites

C84.90 - C84.99 - Opens in a new window Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell
lymphomas, unspecified, extranodal and solid organ sites

C85.10 - C86.6 - Opens in a new window Unspecified B-cell lymphoma, unspecified site - Primary cutaneous CD30-positive T-
cell proliferations

C88.2 - C91.62 - Opens in a new window Heavy chain disease - Prolymphocytic leukemia of T-cell type, in relapse

C91.A0 - C91.Z2 - Opens in a new window Mature B-cell leukemia Burkitt-type not having achieved remission - Other lymphoid
leukemia, in relapse

C91.90 - C91.92 - Opens in a new window Lymphoid leukemia, unspecified not having achieved remission - Lymphoid leukemia,
unspecified, in relapse

C92.00 - C92.62 - Opens in a new window Acute myeloblastic leukemia, not having achieved remission - Acute myeloid leukemia
with 11q23-abnormality in relapse

C92.A0 - C92.Z2 - Opens in a new window Acute myeloid leukemia with multilineage dysplasia, not having achieved remission -
Other myeloid leukemia, in relapse

C92.90 - C92.92 - Opens in a new window Myeloid leukemia, unspecified, not having achieved remission - Myeloid leukemia,
unspecified in relapse

C93.00 - C93.32 - Opens in a new window Acute monoblastic/monocytic leukemia, not having achieved remission - Juvenile
myelomonocytic leukemia, in relapse

C93.Z0 - C93.Z2 - Opens in a new window Other monocytic leukemia, not having achieved remission - Other monocytic leukemia,
in relapse

C93.90 - C93.92 - Opens in a new window Monocytic leukemia, unspecified, not having achieved remission - Monocytic leukemia,
unspecified in relapse

C94.00 - C94.32 - Opens in a new window Acute erythroid leukemia, not having achieved remission - Mast cell leukemia, in
relapse

C94.80 - C96.4 - Opens in a new window Other specified leukemias not having achieved remission - Sarcoma of dendritic cells
(accessory cells)

C96.A - C96.Z - Opens in a new window Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic
and related tissue

C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D03.0 - D03.9 - Opens in a new window Melanoma in situ of lip - Melanoma in situ, unspecified

D45 Polycythemia vera

E83.52 Hypercalcemia

M81.0 - M81.8 - Opens in a new window Age-related osteoporosis without current pathological fracture - Other osteoporosis
without current pathological fracture

M85.9 Disorder of bone density and structure, unspecified

M88.0 - M88.9 - Opens in a new window Osteitis deformans of skull - Osteitis deformans of unspecified bone

M89.9 Disorder of bone, unspecified



CPT/HCPCS Codes

J9310 INJECTION, RITUXIMAB, 100 MG




Coverage Indications, Limitations, and/or Medical Necessity


Indications

FDA:

Non-Hodgkin's Lymphoma (NHL).
Chronic Lymphocytic Leukemia (CLL).
Rheumatoid Arthritis (RA) in combination with methotrexate in adult patients with moderately- to severely-active RA who have inadequate response to one or more TNF antagonist therapies.
Wegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA) in adult patients in combination with glucocorticoids.

Off Label Use:

Waldenstrom's macroglobulinemia - relapsed or refractory
Thrombocytopenic purpura, immune or idiopathic
Renal transplant
prophylaxis - reduction of renal transplant rejection (pre and post) by reducing HLA/ABO antibodies in highly sensitized patients
acute rejection - reducing HLA/ABO antibodies
Pemphigus
Autoimmune hemolytic anemias
Acute Lymphoblastic Leukemia (ALL)


ICD-10 CODE DESCRIPTION

C82.00 - C84.79 - Opens in a new window Follicular lymphoma grade I, unspecified site - Anaplastic large cell lymphoma, ALK-
negative, extranodal and solid organ sites
C84.A0 - C84.Z9 - Opens in a new window Cutaneous T-cell lymphoma, unspecified, unspecified site - Other mature T/NK-cell
lymphomas, extranodal and solid organ sites

C84.90 - C84.99 - Opens in a new window Mature T/NK-cell lymphomas, unspecified, unspecified site - Mature T/NK-cell
lymphomas, unspecified, extranodal and solid organ sites

C85.10 - C88.0 - Opens in a new window Unspecified B-cell lymphoma, unspecified site - Waldenstrom macroglobulinemia

C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

C91.00 - C91.01 - Opens in a new window Acute lymphoblastic leukemia not having achieved remission - Acute lymphoblastic
leukemia, in remission

C91.10 - C91.12 - Opens in a new window Chronic lymphocytic leukemia of B-cell type not having achieved remission - Chronic
lymphocytic leukemia of B-cell type in relapse

C91.40 Hairy cell leukemia not having achieved remission

C91.42 Hairy cell leukemia, in relapse
C96.0 - C96.4 - Opens in a new window Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis - Sarcoma
of dendritic cells (accessory cells)

C96.A - C96.Z - Opens in a new window Histiocytic sarcoma - Other specified malignant neoplasms of lymphoid, hematopoietic
and related tissue

C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D47.3 Essential (hemorrhagic) thrombocythemia

D59.0 - D59.1 - Opens in a new window Drug-induced autoimmune hemolytic anemia - Other autoimmune hemolytic anemias
D69.3 - D69.42 - Opens in a new window Immune thrombocytopenic purpura - Congenital and hereditary thrombocytopenia purpura

E88.01 Alpha-1-antitrypsin deficiency

G70.01 Myasthenia gravis with (acute) exacerbation

L10.0 - L10.9 - Opens in a new window Pemphigus vulgaris - Pemphigus, unspecified

L12.0 - L12.1 - Opens in a new window Bullous pemphigoid - Cicatricial pemphigoid

L12.8 - L12.9 - Opens in a new window Other pemphigoid - Pemphigoid, unspecified
M05.00 - M05.09 - Opens in a new window Felty's syndrome, unspecified site - Felty's syndrome, multiple sites


Group 1 Codes:
J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG


Coverage Indications, Limitations, and/or Medical Necessity

Indications

FDA:

Pancreatic cancer;
Non-small cell lung cancer;
Breast cancer;
Ovarian cancer
Off Label Use:

Bladder cancer - metastatic bladder (urothelial) cancer;
Uterine neoplasms, uterine sarcoma;
Head and neck cancers – cancer of the nasopharynx;
Hodgkins and non-Hodgkin’s lymphomas;
Germ cell tumors - ovarian;
Fallopian tube cancer;
Primary peritoneal cancer
Cancer of the thymus


ICD-10 CODE DESCRIPTION

C14.0 - C14.8 - Opens in a new window Malignant neoplasm of pharynx, unspecified - Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C16.9 Malignant neoplasm of stomach, unspecified

C22.1 Intrahepatic bile duct carcinoma

C23 - C25.9 - Opens in a new window Malignant neoplasm of gallbladder - Malignant neoplasm of pancreas, unspecified

C33 - C37 - Opens in a new window Malignant neoplasm of trachea - Malignant neoplasm of thymus

C38.1 - C38.3 - Opens in a new window Malignant neoplasm of anterior mediastinum - Malignant neoplasm of mediastinum, part unspecified

C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura

C45.1 Mesothelioma of peritoneum

C45.9 Mesothelioma, unspecified

C47.0 - C50.929 - Opens in a new window Malignant neoplasm of peripheral nerves of head, face and neck - Malignant neoplasm of unspecified site of unspecified male breast

C53.0 Malignant neoplasm of endocervix

C54.0 - C57.4 - Opens in a new window Malignant neoplasm of isthmus uteri - Malignant neoplasm of uterine adnexa, unspecified

C58 Malignant neoplasm of placenta

C62.00 - C62.92 - Opens in a new window Malignant neoplasm of unspecified undescended testis - Malignant neoplasm of left testis, unspecified whether descended or undescended

C65.1 - C67.9 - Opens in a new window Malignant neoplasm of right renal pelvis - Malignant neoplasm of bladder, unspecified

C68.9 Malignant neoplasm of urinary organ, unspecified

C75.3 Malignant neoplasm of pineal gland


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