Aetna considers inpatient hospitalization medically necessary for the administration of chemotherapy for members who meet any of the following criteria:
Initial dose of chemotherapy while hospitalized for diagnosis of cancer,
Members who are at risk for tumor lysis syndrome, for example:
- Diagnosis of acute leukemia
- Diagnosis of chronic leukemia with blast crisis
- Member is undergoing first course of therapy for small cell lung cancer
- Member is undergoing lymphoma induction therapy,
Members receiving chemotherapy that necessitates hydration, for example:
- Continuous infusion of cytarabine
- Continuous infusion of gallium nitrate
- High-dose methotrexate (over 1 g/m2)
- Ifosfamide with intravenous mesna
Members requiring monitoring for allergic reactions to cremphor oil, for example:
- Docetaxel via 24-hour infusion for 1st/2nd course
- Paclitaxel via 24-hour infusion for 1st/2nd course,
Members receiving chemotherapy by continuous infusion who do not have central venous access (e.g., Hickman), for example:
- 5-fluorouracil (5-FU)
- Floxuridine (FUDR)
- Nitrogen mustard
Members with impaired cardiac reserve or renal insufficiency requiring monitoring for intravenous fluid overload,
Members with other precipitating reasons for admission, such as respiratory or metabolic instability,
Treatment demonstrably causes vomiting severe enough to result in dehydration/hypotension, unmanageable in an infusion center or by home care measures,
Special chemotherapeutic procedures, for example:
- Intra-arterial chemotherapy
- Intra-hepatic chemotherapy (see CPB 0268 - Liver and Other Neoplasms - Treatment Approaches)
- 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.
The above policy is based on the following references:
|CPT codes covered if selection criteria are met:
|96401 - 96549
|99221 - 99239
||Hospital inpatient services
|HCPCS codes covered if selection criteria are met:
||Injection, gallium nitrate, 1 mg
||Methotrexate, oral, 2.5 mg
|J9000 - J9999
||Injection, teniposide, 50 mg
|ICD-9 codes covered if selection criteria are met:
|140.0 - 208.91, 230.0 - 234.9
|Other ICD-9 codes related to the CPB:
|270.0 - 279.9
||Other metabolic and immunity disorders
|390 - 459.9
||Diseases of the circulatory system
|460 - 519.9
||Diseases of the respiratory system
|580.0 - 593.9
||Diseases of the genitourinary system
|787.01 - 787.03
||Nausea and vomiting
||Adverse effects of antineoplastic and immunosuppressive drugs
|V58.11 - V58.12
||Encounter for antineoplastic chemotherapy and immunotherapy
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