Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Medicare law defines those drugs that are eligible to be covered under the prescription drug benefit. Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Social Security Act, Section 1860D-2(e)(2)(B). Medicare Part B local policy states that oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen are covered under the following conditions: - Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as anti-emetics - The oral anti-emetic must either be administered by the treating physician or in accordance with a written order from the physician as part of a cancer chemotherapy regimen; - Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within two hours of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time - The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. Medicare Benefit Policy Manual, Chapter 15, Section 50.5.4. A 3-drug combination regimen consisting of an NK-1 antagonist, a 5HT3 antagonist and dexamethasone is covered when all of the criteria above are met and all 3 drugs are given in combination. If the NK-1 antagonist and/or dexamethasone is given as an oral anti-emetic outside of the 3-drug regimen, claims will be denied as statutorily non-covered, no benefit. There are three NK-1 antagonists approved for this use, Aprepitant (J8501), rolapitant (J8670) and netupitant/palonosetron (multiple codes). Covered 3-drug regimens are Aprepitant (J8501) or rolapitant (J8670) are covered when given as part of a 3-drug regimen that includes a 5HT3 antagonist (Q0162, Q0166, or Q0180) and dexamethasone (J8540). Netupitant/palonosetron is covered when given in conjunction with dexamethasone (J8540). A separate 5HT3 antagonist is not needed. Netupitant/palonosetron has had multiple HCPCS codes assigned, depending on the date of service. If all of the above criteria are met, the quantity of oral anti-emetic drugs covered for each episode of chemotherapy cannot exceed the initial loading dose plus 48 hours of therapy. However, for the drugs granisetron (Q0166) and dolasetron (Q0180), the quantity of drugs covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy. Quantities of drugs in excess of these amounts are non-covered. You can find this rule at Noridian Administrative Services, Policy Article for Oral Antiemetic Drugs (A52480) or CGS Administrators, LLC, Policy Article for Oral Antiemetic Drugs (A52480).The Part D Plan contract states that the Plan cannot cover drugs that would be covered under Medicare Part A or Part B. Please refer to the Plan's Evidence of Coverage.