Zoladex® (goserelin acetate) (Precertification not required)
Policy Number: PH-90151
Subcutaneous
Last Review Date: 04/04/2024
Date of Origin: 11/28/2011
Dates Reviewed: 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 04/2019, 04/2020, 04/2021, 04/2022, 10/2022, 04/2023, 04/2024
|
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization
- Endometriosis: Coverage will be provided for 6 months and may NOT be renewed.
- Endometrial Thinning: Coverage will be provided for 2 doses only (given 4 weeks apart) and may NOT be renewed.
- All other indications: Coverage will be provided for 12 months and may be renewed.
- Dosing Limits
A. Quantity Limit (max daily dose) [NDC Unit]:
- 3.6mg injection – 1 injection every 28 days
- 10.8mg injection – 1 injection every 12 weeks (Prostate and Breast Cancer only)
B. Max Units (per dose and over time) [HCPCS Unit]:
- Prostate & Breast Cancer – 3 billable units every 84 days
- All Other Indications – 1 billable unit every 28 days
- Initial Approval Criteria 1
Coverage is provided in the following conditions:
- Patient is at least 18 years of age; AND
Universal Criteria 1,2
- Females of reproductive potential must have a negative pregnancy test prior to start of therapy and will use an effective method of nonhormonal contraception during treatment and for 12 weeks after treatment (Note: This excludes use in patients receiving palliative treatment of advanced breast cancer); AND
Breast Cancer † ‡ 2,3
- Patient is a pre- or peri-menopausal woman; AND
- Patient has hormone receptor-positive disease; AND
- Used in combination with adjuvant endocrine therapy; OR
- Used in combination with endocrine therapy for recurrent unresectable or stage IV (M1) disease; OR
- Used as palliative treatment for advanced disease; OR
- Patient has hormone receptor-positive disease; AND
- Patient is a male (sex assigned at birth); AND
- Used in combination with aromatase inhibitor therapy
Prostate Cancer † 1-3
Dysfunctional Uterine Bleeding (Endometrial Thinning) † 2
- Used prior to endometrial ablation
Endometriosis † 2
- Patient has not received prior-treatment with a gonadotropin releasing hormone (GnRH) agonist for this indication within a 6-month prior period
Ovarian Cancer ‡ 3
- Used as a single agent; AND
- Patient has a diagnosis of Epithelial Ovarian Cancer OR Fallopian Tube Cancer OR Primary Peritoneal Cancer (includes Mucinous Carcinoma, Clear Cell Carcinoma, Carcinosarcoma-Mixed Malignant Müllerian Tumors, and Grade 1 Endometrioid Carcinoma); AND
- Patient has persistent or recurrent disease (excluding immediate treatment of biochemical relapse); OR
- Patient has a diagnosis of Low-grade Serous Carcinoma; AND
- Patient has recurrent disease; AND
- Patient has received prior therapy with an aromatase inhibitor; OR
- Patient has a diagnosis of Epithelial Ovarian Cancer OR Fallopian Tube Cancer OR Primary Peritoneal Cancer (includes Mucinous Carcinoma, Clear Cell Carcinoma, Carcinosarcoma-Mixed Malignant Müllerian Tumors, and Grade 1 Endometrioid Carcinoma); AND
- Patient has a diagnosis of stage II-IV granulosa cell tumors of the ovary; AND
- Patient has relapsed disease
† FDA Approved Indication(s), ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1
Coverage can be renewed based upon the following criteria:
- Patient continues to meet the universal and other indication-specific relevant criteria identified in section III; AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: severe QT/QTc interval prolongation, severe hyperglycemia and diabetes, cardiovascular disease (e.g., myocardial infarction, stroke, etc.), hypercalcemia, severe injection site and vascular injury (e.g., pain, hematoma, hemorrhage and hemorrhagic shock, etc.), tumor flare phenomenon, severe hypersensitivity reactions, cervical resistance, new or worsening depression, etc.; AND
Prostate Cancer, Breast Cancer, or Ovarian Cancer
- Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread
Endometriosis/ Dysfunctional Uterine Bleeding (Endometrial Thinning)
- May not be renewed
- Dosage/Administration 1,2,4-6
|
Indication |
Dose |
|
Breast Cancer |
Administer 3.6 mg depot every 4 weeks OR Administer 10.8 mg depot every 12 weeks |
|
Dysfunctional Uterine Bleeding (Endometrial Thinning) |
(3.6 mg only) Administer 3.6 mg for 1 or 2 doses with each depot given 28 days apart.
|
|
Endometriosis |
(3.6 mg only) Administer 3.6 mg depot every 28 days for 6 months |
|
Ovarian Cancer |
(3.6 mg only) Administer 3.6 mg depot every 4 weeks |
|
Prostate Cancer |
Stage B2-C Prostatic Carcinoma
Palliative Treatment of Advanced Prostate Cancer
OR
|
- Billing Code/Availability Information
HCPCS Code:
- J9202 – Goserelin acetate implant, per 3.6 mg; 1 billable unit = 3.6 mg
NDC:
- Zoladex 10.8mg 3-Month Implant: 70720-0951-XX
- Zoladex 3.6mg Implant: 70720-0950-XX
- References
- Zoladex 10.8mg [package insert]. Deerfield, IL; TerSera Therapeutics LLC; December 2020. Accessed March 2024.
- Zoladex 3.6mg [package insert]. Deerfield, IL; TerSera Therapeutics LLC; March 2023. Accessed March 2024.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for goserelin acetate National Comprehensive Cancer Network, 2024. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed March 2024.
- Noguchi S, Kim HJ, Jesena A, et al. Phase 3, open-label, randomized study comparing 3-monthly with monthly goserelin in pre-menopausal women with estrogen receptor-positive advanced breast cancer. Breast Cancer. 2016; 23(5): 771–779. Published online 2015 Sep 9. doi: 10.1007/s12282-015-0637-4.
- Zidan J., Zohar S., Mijiritzky I. et al. (2002). Treating relapsed epithelial ovarian cancer with luteinizing hormone-releasing agonist (goserelin) after failure of chemotherapy. Isr Med Assoc J, 4(8), 597-9.
- Hasan, J., Ton, N., Mullamitha, S. et al. Phase II trial of tamoxifen and goserelin in recurrent epithelial ovarian cancer. British journal of cancer 93.6 (2005): 647-651.
- National Government Services, Inc. Local Coverage Article: Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A52453). Centers for Medicare & Medicaid Services, Inc. Updated on 11/20/2023 with effective date 01/01/2023. Accessed March 2024.
- Palmetto GBA. Local Coverage Article: Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A59160). Centers for Medicare & Medicaid Services, Inc. Updated on 02/07/2024 with effective date 03/15/2024. Accessed March 2024.
Appendix 1 – Covered Diagnosis Codes
|
ICD-10 |
ICD-10 Description |
|
C48.1 |
Malignant neoplasm of specified parts of peritoneum |
|
C48.2 |
Malignant neoplasm of peritoneum, unspecified |
|
C48.8 |
Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum |
|
C50.011 |
Malignant neoplasm of nipple and areola, right female breast |
|
C50.012 |
Malignant neoplasm of nipple and areola, left female breast |
|
C50.019 |
Malignant neoplasm of nipple and areola, unspecified female breast |
|
C50.021 |
Malignant neoplasm of nipple and areola, right female breast |
|
C50.022 |
Malignant neoplasm of nipple and areola, left female breast |
|
C50.029 |
Malignant neoplasm of nipple and areola, unspecified female breast |
|
C50.111 |
Malignant neoplasm of central portion of right female breast |
|
C50.112 |
Malignant neoplasm of central portion of left female breast |
|
C50.119 |
Malignant neoplasm of central portion of unspecified female breast |
|
C50.121 |
Malignant neoplasm of central portion of right male breast |
|
C50.122 |
Malignant neoplasm of central portion of left male breast |
|
C50.129 |
Malignant neoplasm of central portion of unspecified male breast |
|
C50.211 |
Malignant neoplasm of upper-inner quadrant of right female breast |
|
C50.212 |
Malignant neoplasm of upper-inner quadrant of left female breast |
|
C50.219 |
Malignant neoplasm of upper-inner quadrant of unspecified female breast |
|
C50.221 |
Malignant neoplasm of upper-inner quadrant of right male breast |
|
C50.222 |
Malignant neoplasm of upper-inner quadrant of left male breast |
|
C50.229 |
Malignant neoplasm of upper-inner quadrant of unspecified male breast |
|
C50.311 |
Malignant neoplasm of lower-inner quadrant of right female breast |
|
C50.312 |
Malignant neoplasm of lower-inner quadrant of left female breast |
|
C50.319 |
Malignant neoplasm of lower-inner quadrant of unspecified female breast |
|
C50.321 |
Malignant neoplasm of lower-inner quadrant of right male breast |
|
C50.322 |
Malignant neoplasm of lower-inner quadrant of left male breast |
|
C50.329 |
Malignant neoplasm of lower-inner quadrant of unspecified male breast |
|
C50.411 |
Malignant neoplasm of upper-outer quadrant of right female breast |
|
C50.412 |
Malignant neoplasm of upper-outer quadrant of left female breast |
|
C50.419 |
Malignant neoplasm of upper-outer quadrant of unspecified female breast |
|
C50.421 |
Malignant neoplasm of upper-outer quadrant of right male breast |
|
C50.422 |
Malignant neoplasm of upper-outer quadrant of left male breast |
|
C50.429 |
Malignant neoplasm of upper-outer quadrant of unspecified male breast |
|
C50.511 |
Malignant neoplasm of lower-outer quadrant of right female breast |
|
C50.512 |
Malignant neoplasm of lower-outer quadrant of left female breast |
|
C50.519 |
Malignant neoplasm of lower-outer quadrant of unspecified female breast |
|
C50.521 |
Malignant neoplasm of lower-outer quadrant of right male breast |
|
C50.522 |
Malignant neoplasm of lower-outer quadrant of left male breast |
|
C50.529 |
Malignant neoplasm of lower-outer quadrant of unspecified male breast |
|
C50.611 |
Malignant neoplasm of axillary tail of right female breast |
|
C50.612 |
Malignant neoplasm of axillary tail of left female breast |
|
C50.619 |
Malignant neoplasm of axillary tail of unspecified female breast |
|
C50.621 |
Malignant neoplasm of axillary tail of right male breast |
|
C50.622 |
Malignant neoplasm of axillary tail of left male breast |
|
C50.629 |
Malignant neoplasm of axillary tail of unspecified male breast |
|
C50.811 |
Malignant neoplasm of overlapping sites of right female breast |
|
C50.812 |
Malignant neoplasm of overlapping sites of left female breast |
|
C50.819 |
Malignant neoplasm of overlapping sites of unspecified female breast |
|
C50.821 |
Malignant neoplasm of overlapping sites of right male breast |
|
C50.822 |
Malignant neoplasm of overlapping sites of left male breast |
|
C50.829 |
Malignant neoplasm of overlapping sites of unspecified male breast |
|
C50.911 |
Malignant neoplasm of unspecified site of right female breast |
|
C50.912 |
Malignant neoplasm of unspecified site of left female breast |
|
C50.919 |
Malignant neoplasm of unspecified site of unspecified female breast |
|
C50.921 |
Malignant neoplasm of unspecified site of right male breast |
|
C50.922 |
Malignant neoplasm of unspecified site of left male breast |
|
C50.929 |
Malignant neoplasm of unspecified site of unspecified male breast |
|
C56.1 |
Malignant neoplasm of right ovary |
|
C56.2 |
Malignant neoplasm of left ovary |
|
C56.3 |
Malignant neoplasm of bilateral ovaries |
|
C56.9 |
Malignant neoplasm of unspecified ovary |
|
C57.00 |
Malignant neoplasm of unspecified fallopian tube |
|
C57.01 |
Malignant neoplasm of right fallopian tube |
|
C57.02 |
Malignant neoplasm of left fallopian tube |
|
C57.10 |
Malignant neoplasm of unspecified broad ligament |
|
C57.11 |
Malignant neoplasm of right broad ligament |
|
C57.12 |
Malignant neoplasm of left broad ligament |
|
C57.20 |
Malignant neoplasm of unspecified round ligament |
|
C57.21 |
Malignant neoplasm of right round ligament |
|
C57.22 |
Malignant neoplasm of left round ligament |
|
C57.3 |
Malignant neoplasm of parametrium |
|
C57.4 |
Malignant neoplasm of uterine adnexa, unspecified |
|
C57.7 |
Malignant neoplasm of other specified female genital organs |
|
C57.8 |
Malignant neoplasm of overlapping sites of female genital organs |
|
C57.9 |
Malignant neoplasm of female genital organ, unspecified |
|
C61 |
Malignant neoplasm of prostate |
|
N80.00 |
Endometriosis of the uterus, unspecified |
|
N80.01 |
Superficial endometriosis of the uterus |
|
N80.02 |
Deep endometriosis of the uterus |
|
N80.03 |
Adenomyosis of the uterus |
|
N80.101 |
Endometriosis of right ovary, unspecified depth |
|
N80.102 |
Endometriosis of left ovary, unspecified depth |
|
N80.103 |
Endometriosis of bilateral ovaries, unspecified depth |
|
N80.109 |
Endometriosis of ovary, unspecified side, unspecified depth |
|
N80.111 |
Superficial endometriosis of right ovary |
|
N80.112 |
Superficial endometriosis of left ovary |
|
N80.113 |
Superficial endometriosis of bilateral ovaries |
|
N80.119 |
Superficial endometriosis of ovary, unspecified ovary |
|
N80.121 |
Deep endometriosis of right ovary |
|
N80.122 |
Deep endometriosis of left ovary |
|
N80.123 |
Deep endometriosis of bilateral ovaries |
|
N80.129 |
Deep endometriosis of ovary, unspecified ovary |
|
N80.201 |
Endometriosis of right fallopian tube, unspecified depth |
|
N80.202 |
Endometriosis of left fallopian tube, unspecified depth |
|
N80.203 |
Endometriosis of bilateral fallopian tubes, unspecified depth |
|
N80.209 |
Endometriosis of unspecified fallopian tube, unspecified depth |
|
N80.211 |
Superficial endometriosis of right fallopian tube |
|
N80.212 |
Superficial endometriosis of left fallopian tube |
|
N80.213 |
Superficial endometriosis of bilateral fallopian tubes |
|
N80.219 |
Superficial endometriosis of unspecified fallopian tube |
|
N80.221 |
Deep endometriosis of right fallopian tube |
|
N80.222 |
Deep endometriosis of left fallopian tube |
|
N80.223 |
Deep endometriosis of bilateral fallopian tubes |
|
N80.229 |
Deep endometriosis of unspecified fallopian tube |
|
N80.30 |
Endometriosis of pelvic peritoneum, unspecified |
|
N80.311 |
Superficial endometriosis of the anterior cul-de-sac |
|
N80.312 |
Deep endometriosis of the anterior cul-de-sac |
|
N80.319 |
Endometriosis of the anterior cul-de-sac, unspecified depth |
|
N80.321 |
Superficial endometriosis of the posterior cul-de-sac |
|
N80.322 |
Deep endometriosis of the posterior cul-de-sac |
|
N80.329 |
Endometriosis of the posterior cul-de-sac, unspecified depth |
|
N80.331 |
Superficial endometriosis of the right pelvic sidewall |
|
N80.332 |
Superficial endometriosis of the left pelvic sidewall |
|
N80.333 |
Superficial endometriosis of bilateral pelvic sidewall |
|
N80.339 |
Superficial endometriosis of pelvic sidewall, unspecified side |
|
N80.341 |
Deep endometriosis of the right pelvic sidewall |
|
N80.342 |
Deep endometriosis of the left pelvic sidewall |
|
N80.343 |
Deep endometriosis of the bilateral pelvic sidewall |
|
N80.349 |
Deep endometriosis of the pelvic sidewall, unspecified side |
|
N80.351 |
Endometriosis of the right pelvic sidewall, unspecified depth |
|
N80.352 |
Endometriosis of the left pelvic sidewall, unspecified depth |
|
N80.353 |
Endometriosis of bilateral pelvic sidewall, unspecified depth |
|
N80.359 |
Endometriosis of pelvic sidewall, unspecified side, unspecified depth |
|
N80.361 |
Superficial endometriosis of the right pelvic brim |
|
N80.362 |
Superficial endometriosis of the left pelvic brim |
|
N80.363 |
Superficial endometriosis of bilateral pelvic brim |
|
N80.369 |
Superficial endometriosis of the pelvic brim, unspecified side |
|
N80.371 |
Deep endometriosis of the right pelvic brim |
|
N80.372 |
Deep endometriosis of the left pelvic brim |
|
N80.373 |
Deep endometriosis of bilateral pelvic brim |
|
N80.379 |
Deep endometriosis of the pelvic brim, unspecified side |
|
N80.381 |
Endometriosis of the right pelvic brim, unspecified depth |
|
N80.382 |
Endometriosis of the left pelvic brim, unspecified depth |
|
N80.383 |
Endometriosis of bilateral pelvic brim, unspecified depth |
|
N80.389 |
Endometriosis of the pelvic brim, unspecified side, unspecified depth |
|
N80.3A1 |
Superficial endometriosis of the right uterosacral ligament |
|
N80.3A2 |
Superficial endometriosis of the left uterosacral ligament |
|
N80.3A3 |
Superficial endometriosis of the bilateral uterosacral ligament(s) |
|
N80.3A9 |
Superficial endometriosis of the uterosacral ligament(s), unspecified side |
|
N80.3B1 |
Deep endometriosis of the right uterosacral ligament |
|
N80.3B2 |
Deep endometriosis of the left uterosacral ligament |
|
N80.3B3 |
Deep endometriosis of bilateral uterosacral ligament(s) |
|
N80.3B9 |
Deep endometriosis of the uterosacral ligament(s), unspecified side |
|
N80.3C1 |
Endometriosis of the right uterosacral ligament, unspecified depth |
|
N80.3C2 |
Endometriosis of the left uterosacral ligament, unspecified depth |
|
N80.3C3 |
Endometriosis of bilateral uterosacral ligament(s), unspecified depth |
|
N80.3C9 |
Endometriosis of the uterosacral ligament(s), unspecified side, unspecified depth |
|
N80.391 |
Superficial endometriosis of the pelvic peritoneum, other specified sites |
|
N80.392 |
Deep endometriosis of the pelvic peritoneum, other specified sites |
|
N80.399 |
Endometriosis of the pelvic peritoneum, other specified sites, unspecified depth |
|
N80.40 |
Endometriosis of rectovaginal septum, unspecified involvement of vagina |
|
N80.41 |
Endometriosis of rectovaginal septum without involvement of vagina |
|
N80.42 |
Endometriosis of rectovaginal septum with involvement of vagina |
|
N80.50 |
Endometriosis of intestine, unspecified |
|
N80.511 |
Superficial endometriosis of the rectum |
|
N80.512 |
Deep endometriosis of the rectum |
|
N80.519 |
Endometriosis of the rectum, unspecified depth |
|
N80.521 |
Superficial endometriosis of the sigmoid colon |
|
N80.522 |
Deep endometriosis of the sigmoid colon |
|
N80.529 |
Endometriosis of the sigmoid colon, unspecified depth |
|
N80.531 |
Superficial endometriosis of the cecum |
|
N80.532 |
Deep endometriosis of the cecum |
|
N80.539 |
Endometriosis of the cecum, unspecified depth |
|
N80.541 |
Superficial endometriosis of the appendix |
|
N80.542 |
Deep endometriosis of the appendix |
|
N80.549 |
Endometriosis of the appendix, unspecified depth |
|
N80.551 |
Superficial endometriosis of other parts of the colon |
|
N80.552 |
Deep endometriosis of other parts of the colon |
|
N80.559 |
Endometriosis of other parts of the colon, unspecified depth |
|
N80.561 |
Superficial endometriosis of the small intestine |
|
N80.562 |
Deep endometriosis of the small intestine |
|
N80.569 |
Endometriosis of the small intestine, unspecified depth |
|
N80.A0 |
Endometriosis in cutaneous scar |
|
N80.A1 |
Endometriosis of bladder, unspecified depth |
|
N80.A2 |
Superficial endometriosis of bladder |
|
N80.A41 |
Deep endometriosis of bladder |
|
N80.A42 |
Superficial endometriosis of right ureter |
|
N80.A43 |
Superficial endometriosis of left ureter |
|
N80.A49 |
Superficial endometriosis of bilateral ureters |
|
N80.A51 |
Superficial endometriosis of unspecified ureter |
|
N80.A52 |
Deep endometriosis of right ureter |
|
N80.A53 |
Deep endometriosis of left ureter |
|
N80.A59 |
Deep endometriosis of bilateral ureters |
|
N80.A61 |
Deep endometriosis of unspecified ureter |
|
N80.A62 |
Endometriosis of right ureter, unspecified depth |
|
N80.A63 |
Endometriosis of left ureter, unspecified depth |
|
N80.A69 |
Endometriosis of bilateral ureters, unspecified depth |
|
N80.B1 |
Endometriosis of unspecified ureter, unspecified depth |
|
N80.B2 |
Endometriosis of pleura |
|
N80.B31 |
Endometriosis of lung |
|
N80.B32 |
Superficial endometriosis of diaphragm |
|
N80.B39 |
Deep endometriosis of diaphragm |
|
N80.B4 |
Endometriosis of diaphragm, unspecified depth |
|
N80.B5 |
Endometriosis of the pericardial space |
|
N80.B6 |
Endometriosis of the mediastinal space |
|
N80.C0 |
Endometriosis of cardiothoracic space |
|
N80.C10 |
Endometriosis of the abdomen, unspecified |
|
N80.C11 |
Endometriosis of the anterior abdominal wall, subcutaneous tissue |
|
N80.C19 |
Endometriosis of the anterior abdominal wall, fascia and muscular layers |
|
N80.C2 |
Endometriosis of the anterior abdominal wall, unspecified depth |
|
N80.C3 |
Endometriosis of the umbilicus |
|
N80.C4 |
Endometriosis of the inguinal canal |
|
N80.C9 |
Endometriosis of extra-pelvic abdominal peritoneum |
|
N80.D0 |
Endometriosis of other site of abdomen |
|
N80.D1 |
Endometriosis of the pelvic nerves, unspecified |
|
N80.D2 |
Endometriosis of the sacral splanchnic nerves |
|
N80.D3 |
Endometriosis of the sacral nerve roots |
|
N80.D4 |
Endometriosis of the obturator nerve |
|
N80.D5 |
Endometriosis of the sciatic nerve |
|
N80.D6 |
Endometriosis of the pudendal nerve |
|
N80.D9 |
Endometriosis of the femoral nerve |
|
N80.9 |
Endometriosis, unspecified |
|
N92.4 |
Excessive bleeding in the premenopausal period |
|
N92.5 |
Other specified irregular menstruation |
|
N93.8 |
Other specified abnormal uterine and vaginal bleeding |
|
Z85.3 |
Personal history of malignant neoplasm of breast |
|
Z85.43 |
Personal history of malignant neoplasm of ovary |
|
Z85.46 |
Personal history of malignant neoplasm of prostate |
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.
|
Medicare Part B Covered Diagnosis Codes |
||
|
Jurisdiction |
NCD/LCA/LCD Document (s) |
Contractor |
|
6, K |
A52453 |
National Government Services, Inc |
|
J, M |
A59160 |
Palmetto GBA |
|
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
|
Jurisdiction |
Applicable State/US Territory |
Contractor |
|
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
|
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
|
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corp (WPS) |
|
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
|
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
|
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corp (WPS) |
|
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
|
J (10) |
TN, GA, AL |
Palmetto GBA |
|
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
|
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
|
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
|
15 |
KY, OH |
CGS Administrators, LLC |
|
|
