Article Detail - JA DME

Original Effective Date: 11/18/2010
Revision Effective Date: 11/01/2013

Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have received questions regarding the coverage requirements in the Oral Antiemetic Drugs (Replacement for Intravenous Drugs) local coverage determination (LCD) and related policy article. Coverage of oral antiemetic drugs is a specific Medicare benefit category found in the Social Security Act, Title XVIII, Section 1861(s)(2)(T) with further instructions for coverage in the Medicare Claims Processing Manual (CMS Internet-Only Publication 100-4, Chapter 17, Section 80.2).

Questions recently raised relate to the requirement that the oral antiemetic must be initiated within two (2) hours of the administration of the chemotherapeutic agent. This means that the first dose of the oral antiemetic drug or drugs (if part of a multi-drug regimen), must be administered to the beneficiary within 2 hours of initiation of the cancer chemotherapeutic regimen. This does not mean that the pharmacy must dispense the drug or fill a prescription within 2 hours of administration of the drug(s). In addition, the amount dispensed must not exceed the maximum dosing time period limitation of 24 or 48 hours as described in the Healthcare Common Procedure Coding System (HCPCS) code descriptor for each drug.

Suppliers should refer to the local coverage determination and related policy article for Oral Antiemetic Drugs (Replacement for Intravenous Drugs) for additional coverage, coding and documentation requirements.