Oral Anticancer Drugs and Oral Antiemetic Drugs - JA DME
Oral Anticancer Drugs and Oral Antiemetic Drugs
Oral anticancer drugs are covered under the oral anticancer drug benefit [Social Security Act §1861(s)(2)(Q)]. Oral Antiemetic Drugs are covered under the Oral Antiemetic Drug benefit (Social Security Act §1861(s)(2)(T)).
Coverage
- Aprepitant for Chemotherapy-Induced EMESIS (110.18) National Coverage Determination (NCD)
- Oral Anticancer Drugs Local Coverage Determination (LCD)
- Oral Anticancer Drugs Policy Article
- Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) Local Coverage Determination (LCD)
- Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) Policy Article
Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Checklist Oral Anticancer Drugs [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Letter - Medical Records [PDF] - Letter may be sent to clinicians to help obtain documentation
- Oral Anticancer Drugs Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
Fees
Tips
ICD 10-Codes Update
NCD 110.18 Aprepitant for Chemo-Induced Emesis has been updated to add ICD-10 diagnosis codes C56.3, C79.63, C84.7A as coverable effective October 1, 2021. ICD-10 diagnosis codes D49.89, D49.4, D49.511, D49.512, D49.6 were removed effective April 1, 2022. See CMS Medicare Learning Network (MLN) Matters (MM) 12480 for details.
Note:
A drug that isn't available in an injectable form does not meet criterion 2. If an oral anticancer drug is used for immunosuppression (rather than the treatment of cancer), criterion 3 is not met and Medicare does not cover the drug under the oral anticancer drug benefit. If the drug is used for immunosuppression following an organ transplant, refer to the Immunosuppressive Drugs policy.
Resources
- CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15 - Self-Administered Drugs and Biologicals
- CMS IOM, Publication 100-04, Chapter 17 - Oral Cancer Drugs and Oral Anti-Emetic Drugs
- CMS Change Request (CR)9386 - Authoritative Sources Used in Determination of "Medically-Accepted Indication" of Drugs and Biologicals Used Off-label in Anti-Cancer Chemotherapeutic Regimen
- National Drug Codes for Oral Anti-Cancer Drugs (OACD)
- NCPDP - NCPDP Companion Document
