Chemotherapy, Inpatient

Number: 0570


Aetna considers inpatient hospitalization medically necessary for the administration of chemotherapy for members who meet any of the following criteria:

  1. Initial dose of chemotherapy while hospitalized for diagnosis of cancer

  2. Members who are at risk for tumor lysis syndrome, for example:

    1. Diagnosis of acute leukemia
    2. Diagnosis of chronic leukemia with blast crisis
    3. Member is undergoing first course of therapy for small cell lung cancer
    4. Member is undergoing lymphoma induction therapy
  3. Members receiving chemotherapy that necessitates hydration, for example:

    1. Cisplatin
    2. Continuous infusion of cytarabine
    3. Continuous infusion of gallium nitrate
    4. High-dose methotrexate (over 1 g/m2)
    5. Ifosfamide with intravenous mesna
    6. Interleukin-2
  4. Members requiring monitoring for allergic reactions to cremphor oil, for example:

    1. Docetaxel via 24-hour infusion for 1st/2nd course
    2. Paclitaxel via 24-hour infusion for 1st/2nd course
  5. Members receiving chemotherapy by continuous infusion who do not have central venous access (e.g., Hickman), for example:

    1. Adriamycin
    2. Cytarabine
    3. Etoposide
    4. 5-fluorouracil (5-FU)
    5. Floxuridine (FUDR)
    6. Mitomycin
    7. Mitoxantrone
    8. Navelbine
    9. Nitrogen mustard
    10. Teniposide
    11. Vinblastine
    12. Vincristine
    13. Vindesine
  6. Members with impaired cardiac reserve or renal insufficiency requiring monitoring for intravenous fluid overload

  7. Members with other precipitating reasons for admission, such as respiratory or metabolic instability

  8. Treatment demonstrably causes vomiting severe enough to result in dehydration/hypotension, unmanageable in an infusion center or by home care measures

  9. Special chemotherapeutic procedures, for example:

    1. Intra-arterial chemotherapy
    2. Intra-hepatic chemotherapy (see CPB 0268 - Liver and Other Neoplasms - Treatment Approaches)
    3. Intra-pleural chemotherapy

Most chemotherapies can be safely administered in the oncologist's office, infusion centers or in the patient's home.  Hospitalization for chemotherapy is now limited to specific situations, reflecting the need for prolonged direct observation, prevention or treatment of anticipated or real side effects, the use of special facilities and the minimization of certain treatment risks that can not be effectively dealt with in an outpatient setting.

Outpatient chemotherapy has the advantages of allowing safe, easy drug administration, respecting the patient's wish to avoid hospitalization and providing a familiar facility, which enhances the patient's physical comfort and psychological well-being.

The most common major complications of chemotherapy are bone marrow suppression, nausea and vomiting and inflammation of the oral mucosa (i.e., stomatitis).  Emerging data suggest that prophylactic oral antibiotics (e.g., 500 mg of levofloxacin daily) reduce the number of hospitalizations in patients whose absolute neutrophil count falls below 1,000/mm3.  Anti-emetic drugs should be given on a regular schedule to prevent nausea and vomiting.  Topical oral anesthetics for the treatment of stomatitis may relieve pain and help maintain adequate oral intake.

CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
ICD-10 codes will become effective as of October 1, 2015:
CPT codes covered if selection criteria are met:
96401 - 96549 Chemotherapy administration
99221 - 99239 Hospital inpatient services
HCPCS codes covered if selection criteria are met:
J1457 Injection, gallium nitrate, 1 mg
J8610 Methotrexate, oral, 2.5 mg
J9000 - J9999 Chemotherapy drugs
Q2017 Injection, teniposide, 50 mg
ICD-10 codes covered if selection criteria are met:
C00.0 - C43.9
C44.0 - C75.9
C76.0 - C86.6
C88.2 - C94.32
C94.80 - C96.4
C96.a - D09.9
Malignant neoplasms

The above policy is based on the following references:
    1. Goroll AH, ed. Primary Care Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:570.
    2. Peters WP, Ross M, Vredenburgh JJ, et al. The use of intensive clinic support to permit outpatient autologous bone marrow transplantation for breast cancer. Semin Oncol. 1994;21(4 Suppl 7):25-31.
    3. Shaw HL. Treatment of the patient with cancer using parenteral electronic drug administration. Cancer. 1992;70 (suppl):993-997.
    4. Figlin RA, Belldegrun A, Moldawer N, et al. Concomitant administration or recombinant human interleukin-2 and recombinant interferon alfa-2A: An active outpatient regimen in metastatic renal cell carcinoma. J Clin Oncol. 1992;10:414-421.
    5. Skubitz K, Hamdan H, Thompson RC. Ambulatory continuous infusion ifosfamide with oral etoposide in advanced sarcomas. Cancer. 1993;72:2963-2969.
    6. Close P, Burkey E, Kazak A, et al. A prospective, controlled evaluation of home chemotherapy for children with cancer. Pediatrics. 1995;95(6):896-900.
    7. Holdsworth MT, Raisch DW, Chavez CM, et al. Economic impact with home delivery of chemotherapy to pediatric oncology patients. Ann Pharmacother. 1997;31(2):140-148.
    8. Watters C. The benefits of providing chemotherapy at home. Prof Nurse. 1997;12(5):367-370.
    9. Dougherty L, Viner C, Young J. Establishing ambulatory chemotherapy at home. Prof Nurse. 1998;13(6):356-358.
    10. Westermann AM, Holtkamp MM, Linthorst GA, et al. At home management of aplastic phase following high-dose chemotherapy with stem-cell rescue for hematological and non-hematological malignancies. Ann Oncol. 1999;10(5):511-517.
    11. Catania PN. Home chemotherapy: Basic concepts. Home Care Provid. 1999;4(2):60-61.
    12. Berman AJ. Supporting the home care client receiving chemotherapy. Home Care Provid. 1999;4(2):81-87.
    13. Rischin D, White MA, Matthews JP, et al. A randomised crossover trial of chemotherapy in the home: Patient preferences and cost analysis. Med J Aust. 2000;173(3):125-127.
    14. King MT, Hall J, Caleo S, et al. Home or hospital? An evaluation of the costs, preferences, and outcomes of domiciliary chemotherapy. Int J Health Serv. 2000;30(3):557-579.
    15. Borras JM, Sanchez-Hernandez A, Navarro M, et al. Compliance, satisfaction, and quality of life of patients with colorectal cancer receiving home chemotherapy or outpatient treatment: A randomised controlled trial. BMJ. 2001;322(7290):826.
    16. Santolaya ME, Alvarez AM, Aviles CL, et al.  Early hospital discharge followed by outpatient management versus continued hospitalization of children with cancer, fever, and neutropenia at low risk for invasive bacterial infection. J Clin Oncol. 2004;22(18):3784-3789.
    17. Boothroyd L, Lehoux P. Home-based chemotherapy for cancer. Issues for patients, caregivers and the health care system. AETMIS; 04-02. Montreal, QC; Agence D'Evaluation des Technologies et des Modes D'Intervention en Sante (AETMIS); May 2004.
    18. Stevens B, Croxford R, McKeever P, et al. Hospital and home chemotherapy for children with leukemia: A randomized cross-over study. Pediatr Blood Cancer. 2006;47(3):285-292.
    19. Löwenberg B, Pabst T, Vellenga E, et al; Dutch-Belgian Cooperative Trial Group for Hemato-Oncology (HOVON) and Swiss Group for Clinical Cancer Research (SAKK) Collaborative Group. Cytarabine dose for acute myeloid leukemia. N Engl J Med. 2011;364(11):1027-1036.

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