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
