This policy is based in part on antiemetic practice guidelines from the National Comprehensive Cancer Network (NCCN) and the American College of Obstetrics and Gynecology (ACOG) practice guidelines on nausea and vomiting of pregnancy.
Aetna considers palonosetron (Aloxi) or fosaprepitant dimeglumine (Emend) antiemetic therapy medically necessary for either of the following indfications: (i) the prevention of acute nausea or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy, including high-dose cisplatin; or (ii) for treatment of chemotherapy-induced nausea or vomiting from low or minimally emetogenic cancer chemotherapy in persons who have an inadequate response or contraindication to intravenous granisetron (Kytril) or ondansetron (Zofran) at the Food and Drug Administration (FDA) recommended dose (see table in Appendix).
Aetna considers granisetron (Kytril) and ondansetron (Zofran) antiemetic intravenous therapy medically necessary for the following indications: (i) prevention of acute and delayed nausea and/or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy including high-dose displatin; and (ii) for treatment of chemotherapy-induced nausea and/or vomiting of low or minimally emetogenic cancer chemotherapy in persons who have an inadequate response or contraindication to oral granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose (see table in Appendix).
Aetna considers intravenous dolasetron (Anzemet) experimental and investigational for prevention of nausea or vomiting from cancer chemotherapy.
Aetna considers dolasetron mesylate (Anzemet), medically necessary for the prevention of radiation-induced nausea or vomiting secondary to total body irradiation (TBI) when intravenous antiemetic therapy with granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers intravenous granisetron (Kytril) or intravenous ondansetron (Zofran) medically necessary for the prevention of radiation-induced nausea and/or vomiting secondary to TBI when oral granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers intravenous palonosetron (Aloxi) and fosaprepitant dimeglumine (Emend) experimental and investigational for the prevention of radiation-induced nausea and vomiting because there is insufficient evidence of their effectiveness for this indication.
Aetna considers intravenous palonosetron (Aloxi), dolasetron mesylate (Anzemet) or fosaprepitant dimeglumine (Emend) medically necessary for the prevention or treatment of post-operative nausea or vomiting when intravenous granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers intravenous granisetron (Kytril) or ondansetron (Zofran) medically necessary for the prevention or treatment of post-operative nausea or vomiting when oral granisetron (Kytril) or ondansetron (Zofran) has failed or is contraindicated.
Note: As with other antiemetics, routine prophylaxis is not recommended for individuals in whom there is little expectation that nausea and/or vomiting will occur post-operatively.
Aetna considers intravenous granisetron (Kytril) or ondansetron (Zofran) antiemetic intravenous therapy medically necessary for severe, intractable, persistent nausea or vomiting during pregnancy when clinical signs of dehydration are present or nausea and vomiting have persisted for more than 3 weeks and all of the following conditions are met:
Oral, sublingual, or rectal antiemetics have failed or are contraindicated including 2 or more of the following:
Other injectable/intravenous antiemetics have failed or are contraindicated including all of the following:
Aetna considers intravenous palonosetron (Aloxi), dolasetron mesylate (Anzemet) or fosaprepitant dimeglumine (Emend) medically necessary for severe, intractable, persistent nausea or vomiting during pregnancy when clinical signs of dehydration are present or nausea and vomiting have persisted for more than 3 weeks and intravenous granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Aetna considers 5-HT3 receptor antagonist antiemetic intravenous therapy experimental and investigational for motion-induced nausea and vomiting (motion-sickness).
Aetna considers granisetron (Kytril) or ondansetron (Zofran) antiemetic intravenous therapy medically necessary for refractory cases of nausea or vomiting for other indications (e.g., bulimia nervosa, cyclic vomiting syndrome, HIV) when oral granisetron (Kytril) or ondansetron (Zofran) has failed or is contraindicated.
Aetna considers intravenous palonosetron (Aloxi), dolasetron mesylate (Anzemet) or fosaprepitant dimeglumine (Emend) medically necessary for refractory cases of nausea or vomiting for other indications (e.g., bulimia nervosa, cyclic vomiting syndrome, HIV) when intravenous granisetron (Kytril) or ondansetron (Zofran) at the FDA recommended dose has failed or is contraindicated.
Note: This policy does not address the use of 5-HT3 receptor antagonists in the emergency room. Serotonin 3 receptor antagonists have been used in the management of acute toxicities (e.g., acetaminophen, theophylline).Background
Serotonin 3 (5-HT3) receptor antagonists [(i.e., palonosetron (Aloxi), dolasetron mesylate (Anzemet), granisetron (Kytril), and ondansetron (Zofran)] are used for the treatment and prevention of post-operative nausea and vomiting as well as nausea and vomiting caused by cancer chemotherapy, radiotherapy, and pregnancy. 5-HT3 receptor antagonists work by blocking serotonin binding at vagal afferents in the gut and in regions of the central nervous system (CNS) involved in emesis.
Antiemetic practice guidelines from the National Comprehensive Cancer Network (NCCN, 2008) recommend antiemetic regimens based upon the emetogenic potential of the chemotherapy drug as well as individual risk factors. The antiemetic regimen for highly emetogenic drugs includes aprepitant, dexamethasone, and a 5-HT3 antagonist with or without lorazepam. The antiemetic regimen for moderately emetogenic drugs includes dexamethosone and a 5-HT3 antagonist (palonosetron is preferred) with or without lorazepam; consider adding aprepitant for select patients (those receiving carboplatin, cyclophosphamide, doxorubixin, epirubicin, ifosfamide, irinotecan, or methotrexate). The antiemetic regimen for low emetogenic drugs includes the following non-5-HT3 anatgonists: dexamethasone with or without lorazepam, prochlorperazine, spansule, or metoclopramide with or without diphenhydramine. For minimal risk chemotherapy, the NCCN guidelines recommend that no routine prophylactic treatment be given.
According to NCCN, the basic strategy of any antiemetic regimen is to prevent nausea/vomiting from occurring, thus, prophylactic antiemetics should be administered before chemotherapy begins and for patients receiving high or moderate emetogenic chemotherapy, antiemetics should continue for at least 4 days. Although oral and intravenous (I.V.) antiemetics have equivalent efficacy, patients who are unable to swallow or digest tablets because of emesis, should be given I.V. antiemetics (NCCN). Breakthrough nausea/vomiting induced by high, moderate and low emetic risk chemotherapy can be very difficult to treat. Adding an additional agent from a different drug class is the general management approach recommended by NCCN as well as adjusting either the intensity or frequency of dosing. Dopamine antagonists, metoclopramide, thiethylperazine, butyrophenones (e.g., halpreridol), corticosteroids, and agents such as lorazepam may be required. Routine around-the-clock administration should be considered, rather than as needed. Also, while not likely to be effective, anecdotal evidence suggests that switching to a different 5-HT3 may be efficacious (NCCN).
Studies have demonstrated that all of the 5-HT3 antagonists are effective and have mild, infrequent side effects, although optimal antiemetic therapy requires concomitant dexamethasone or methylprednisolone, unless the patient can not tolerate corticosteroids (NCCN). According to the NCCN guidelines, dolasetron mesylate, granisetron, and ondansetron are effective in preventing acute emesis but are less effective for delayed emesis compared with palonosetron. Palonosetron is effective for preventing both delayed and acute emesis and is the preferred medication for patients undergoing moderate emetic risk chemotherapy (NCCN). In the trial data submitted to the Food and Drug Adminsitration (FDA) for licensure, palonosetron achieved equivalent or superior results compared to the control arms (ondansetron and dolasetron), especially with regard to delayed nausea. The side effect and safety profile of palonosetron has been demonstrated to be the same as dolasetron mesylate and ondansetron but it has a slightly higher tissue binding affinity for the 5-HT3 receptor and a significantly longer serum half-life than other 5-HT3 antagonists. Palonosetron is administered intravenously and is approved by the FDA as a single dose of 0.25 mg I.V. over 30 seconds on day 1, approximately 30 mins before chemotherapy. Higher doses (e.g., 0.75 mg) were studied and were no more effective than the 0.25 mg dose. Repeat dosing of palonosetron in the days following chemotherapy (e.g., day 2 to 3) or in the setting of multi-day chemotherapy regimens is not supported by the scientific literature.
In December 2010, the FDA released a special announcement that the injection form of dolasetron mesylate (Anzemet) should no longer be used to prevent nausea and vomiting associated with chemotherapy-induced nausea and vomiting (CINV) in pediatric and adult patients. New data demonstrated that intravenous dolasetron can increase the risk of developing an abnormal heart rhythm (torsade de pointes) which can be fatal.
The Multinational Association of Supportive Care in Cancer (MASCC) International Consensus Conference (2005) classified the risk of radiotherapy-induced emesis as follows: (i) high - total body irradiation, (ii) moderate - upper abdomen, (iii) low - lower thorax, pelvis, cranium (radiosurgery) and craniospinal, (iv) minimal risk - head and neck, extremities, cranium and breast (Maranzano et al, 2005). NCCN (2006) antiemesis guidelines for the use of antiemetics in radiotherapy are based on the site of radiation and whether radiotherapy is combined with chemotherapy; when radiotherapy is combined with chemotherapy, prophylaxis is dictated by the emetogenic potential of the chemotherapy regimen. For total body irradiation, NCCN guidelines recommend pretreatment for each day of radiation treatment with either oral ondansetron or oral / I.V. granisetron. For upper abdomen radiation, NCCN guidelines recommend pretreatment for each day of radiation treatment with either oral ondansetron or oral granisetron. NCCN guidelines do not recommend primary treatment for patients receiving radiation to other sites.
Nausea and vomiting are common in pregnancy. Approximately 70 to 85 % of pregnant women experience nausea and/or vomiting. Hyperemesis gravidarum, a severe and intractable form of nausea and vomiting during pregnancy, may result in weight loss, nutritional deficiencies, and dehydration. The peak incidence occurs at 8 to 12 weeks of pregnancy, and symptoms usually resolve by week 16. The American College of Obstetrics and Gynecology (ACOG) (2004) recommend a step-wise approach to alleviating nausea and vomiting in pregnancy, beginning with prevention at the time of conception. Two studies found that women who take a multi-vitamin at the time of conception were less likely to need medical attention for vomiting. While there is little published evidence regarding the efficacy of dietary changes for prevention or treatment of nausea and vomiting of pregnancy, a small study showed that protein meals were more likely to relieve nausea and vomiting of pregnancy than carbohydrate and fatty meals. Other conservative treatments recommended by ACOG included ginger capsules and electrical stimulation or acupressure at the P6 (or Neguian) point on the inside of the wrist. Women with more complicated nausea and vomiting of pregnancy may need pharmacologic therapy. While many conventional antiemetics have been used for nausea and vomiting of pregnancy, it is important to note that no drug has been approved by the FDA for the treatment of nausea and vomiting in pregnancy since Benedictine (an antiemetic no longer available in the U.S. but still widely used in Europe).
According to ACOG guidelines, pharmacologic treatment of nausea and vomiting of pregnancy should begin with pyridoxine (vitamin B6). If there is no improvement, doxylamine (Unisom) should be added with the pyridoxine. A 70 % reduction in nausea and vomiting has been reported with this combination. Doxylamine and pyridoxine are currently available separately without a prescription in the U.S. Several studies involving more than 170,000 exposures have found this combination to be safe with regard to fetal exposure. If this is unsuccessful, adding or switching to antiemetics and antihistamines may be necessary. Medications for which there are some safety data but no conclusive evidence of efficacy include anticholinergics and metoclopramide (Reglan) (ACOG, 2004).
Evidence is limited on the safety and efficacy of ondansetron injectable for treatment of pregnancy-related nausea and vomiting. However, this medication is being prescribed as an off-label use for the treatment of nausea and vomiting of pregnancy due to its reported effectiveness in reducing chemotherapy-induced emesis (ACOG, 2004). In a limited comparative study with other antiemetics, no increased risks of major malformations were reported (Einarson et al, 2004). In a small trial of I.V. therapy in women with hyperemesis gravidarum, no increased benefit was demonstrated with ondansetron over promethazine (Sullivan et al, 1996). However, according to ACOG’s step-wise approach to managing nausea and vomiting of pregnancy, ondansetron may be tried in refractory cases as a last resort. When indicated, ACOG guidelines recommend 8 mg of ondansetron over 15 mins every 12 hrs I.V.
According to the peer-reviewed medical literature, selective 5-HT3 receptor antagonists have been proven safe and effective for the management of post-operative nausea and vomiting (Loewen et al, 2000; Kovac, 2000; Fuji, 2005).
Ondansetron for bulimia nervosa was reported to be effective in 3 small trials by one group of investigators, and may be an option after failure of traditional therapies (Fung and Ferrill, 2001). Additionally, some studies on bulimia nervosa recommend short-term use of antiemetics at the onset of a patient's treatment. Antiemetics are thought to reduce a patient's stimuli to vomit and help patients through the few weeks it takes for antidepressants to become fully effective (Moreno, 2005).
A Prodigy Clinical Practice Recommendation (SCHIN, 2006) on palliative care - nausea/vomiting/malignant bowel obstruction.stated, “[o]ndansetron, tropisetron, granisetron, and dolasetron are rarely indicated in the palliative care setting. Their use is limited to chemotherapy and radiotherapy induced nausea…[t]he role of somatostatin analogues in the relief of nausea and vomiting due to malignant bowel obstruction is not clear.”
In a single-blind, randomized controlleds tudy, Yonemura et al (2009) evaluated the non-inferiority of 1-mg to 3-mg granisetron (GRN) injection for the treatment of acute CINV and assessed the tolerability of GRN given at 1-mg in Japanese cancer patients. Patients with cancer receiving highly emetogenic chemotherapy were enrolled in this study. Patients were randomly assigned to receive GRN at a single dose of 1-mg or 3-mg. The primary endpoint was the rate of complete protection from emetic events (no vomiting, no retching and no need for rescue medication) during the first 24 hrs following the initiation of chemotherapy. There were 89 patients in the 1-mg group and 90 patients in the 3-mg group. Complete protection was achieved in 70 patients (78.7 %) in the 1-mg group and 73 (81.1 %) patients in the 3-mg group. The 1-sided test did not reveal non-inferiority of either dose of GRN to the other at a 5 % significance level. The authors concluded that these findings failed to show the non-inferiority of 1-mg of GRN to 3-mg of GRN administered as a single dose. However, the rate of complete protection from nausea and vomiting was similar in the 2 groups. They stated that given the recommended dosage in the guidelines and the economic need for reduction of medical care expenses in Japan, prophylactic administration of GRN at 1-mg may be an appropriate, alternative treatment for acute CINV in cancer patients.
Results of clinical trials indicated that 5-HT3 receptor antagonists for the reduction of motion sickness have not been proven effective (Levine et al, 2000; Reid et al, 2000).
Broder et al (2014) noted that individual studies have assessed the impact of standard prophylactic therapy with 5-hydroxytryptamine receptor antagonists (5-HT3RAs) for CINV on cost and utilization, but no synthesis of the findings exists. These investigators systematically reviewed published literature on costs and utilization associated with CINV prophylaxis with palonosetron and other 5-HT3RAs. PubMed and the National Institute for Health Research Centre for Reviews and Dissemination databases, conferences of 4 organizations (i.e., Academy of Managed Care Pharmacy, American Society of Clinical Oncology, International Society for Pharmacoeconomics and Outcomes Research, and Multinational Association of Supportive Care in Cancer), and the bibliographies of relevant articles were queried for the medical subject headings and key terms of "ondansetron", "granisetron", "palonosetron", "dolasetron mesylate", "costs", "cost analysis" and "economics". These researchers included records published (full-length articles after 1997 and conference presentations after 2010) in English and with human patients, reporting data on cost and utilization (rescue medication, outpatient and inpatient services) associated with the use of 5-HT3RAs for the treatment or prevention of CINV. Of the 434 identified studies, 32 were included in the current analysis: 7 studies reported costs, 18 reported utilization, and 7 studies reported both. The costs were reported in US dollars (7 studies), in Euros (5 studies), and in Canadian dollars (2 studies). The studies varied in designs, patients, 5-HT3RA regimens, and the definition of outcomes. The US studies reported higher drug costs for CINV prophylaxis with palonosetron compared with ondansetron, lower medical outpatient and inpatient costs for palonosetron versus other 5-HT3RAs, and higher acquisition costs for palonosetron versus ondansetron or other 5-HT3RAs. Fewer patients receiving palonosetron versus with ondansetron or other 5-HT3RAs required rescue medication or used outpatient or inpatient care. In Europe and in Canada, the total pharmacy costs and use of rescue medications reported were lower for patients receiving prophylaxis with palonosetron. The authors concluded that the findings of this analysis showed that prophylaxis with palonosetron for the treatment of CINV is associated with higher acquisition treatment costs, but also with lower use of rescue medications and outpatient and inpatient services compared with ondansetron or other 5-HT3RAs in the United States. They stated that the use of palonosetron as a standard treatment may lead to reduced service utilization for CINV.
Zhou and co-workers (2015) discussed existing and emerging therapeutic options, and examined studies focusing on palonosetron with regards to efficacy, pharmacology, tolerability, safety, and patient-derived outcomes. These investigators performed a literature search using Ovid MEDLINE and EMBASE to identify relevant studies using palonosetron alone or in combination with other anti-emetics. Studies were extracted if they included complete response (CR), complete control (CC), no nausea, no vomiting, and no rescue medications as an end-point. Studies were also included if safety end-points were examined. Palonosetron alone has been shown to improve CR and CC rates for patients receiving low, moderate, or high emetogenic chemotherapy. Rates were further improved with the addition of dexamethasone. Furthermore, the addition of neurokinin-1 receptor antagonists, such as netupitant markedly improved efficacy profiles compared to palonosetron alone. Aprepitant is an anti-emetic that has exhibited positive results in combination with palonosetron. Recently, a new drug consisting of netupitant and palonosetron (NEPA) has demonstrated significantly more effective prevention of CINV. Regardless of the combination, palonosetron has been well-tolerated. The most common adverse events were constipation, headache, fatigue, and dizziness, with the majority of patients describing them as only mild or moderate. The authors concluded that palonosetron, alone or with other anti-emetics, has improved CINV treatment due to its ability to significantly reduce delayed phases of CINV, compared to similar 5-HT3RAs. They stated that palonosetron is both more effective than first generation 5-HT3RAs and safer, as it results in a smaller prolongation of the QTc interval, compared to other 5-HT3RAs.
Tricco and colleagues (2015a) noted that patients may experience nausea and vomiting when undergoing chemotherapy or surgery requiring anesthesia. Serotonin 5-hydroxytryptamine 3 receptor antagonists are effective anti-emetics, yet may cause adverse cardiac events, such as arrhythmia. These investigators identified interventions that mitigate the cardiac risk of 5-HTRAs. Electronic databases, trial registries, and references were searched. Studies on patients undergoing chemotherapy or surgery examining interventions to monitor cardiac risk of 5-HT3 receptor antagonists were included. Search results were screened and data from relevant studies were abstracted in duplicate. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organization of Care (EPOC) group's risk-of-bias tool. Due to a dearth of included studies, meta-analysis was not conducted. A total of 2 randomized clinical trials (RCT) and 1 non-randomized clinical trial (NRCT) were included after screening 7,637 titles and abstracts and 1,554 full-text articles. Intravenous administration of different dolasetron doses was examined in the NRCT, while dolasetron versus ondansetron and palonosetron versus ondansetron were examined in the RCT. Electrocardiogram (ECG) was the only intervention examined to mitigate cardiac harm. No differences in ECG evaluations were observed between dolasetron or palonosetron versus ondansetron after 15 minutes, 24 hours, and 1 week post-administration in the 2 RCTs. Four deaths were observed in 1 RCT, which were deemed unrelated to palonosetron or ondansetron administration. Minor increases in PR and QT intervals were observed in the NRCT for dolasetron dosages greater than 1.2 mg/kg 1 to 2 hours post-administration, but were deemed not clinically relevant. The authors concluded that ECG monitoring of chemotherapy patients administered with 5-HT3RAs did not reveal clinically significant differences in arrhythmia between the medications at the examined time periods. The usefulness of ECG to monitor chemotherapy patients administered with 5-HT3RAs remains unclear, as all patients received ECG monitoring.
Tricco and associates (2015b) stated that 5-HT3 receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients, but these agents may be harmful. These researchers conducted a systematic review on the comparative safety of 5-HTRAs. Searches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or other anti-emetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by 2 reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. Overall, 120 studies and 27,787 patients were included after screening of 7,608 citations and 1,014 full-text articles. Significantly more patients receiving granisetron plus dexamethasone experienced an arrhythmia relative to placebo (odds ratio (OR) 2.96, 95 % confidence interval [CI]: 1.11 to 7.94), ondansetron (OR 3.23, 95 % CI: 1.17 to 8.95), dolasetron (OR 4.37, 95 % CI: 1.51 to 12.62), tropisetron (OR 3.27, 95 % CI: 1.02 to 10.43), and ondansetron plus dexamethasone (OR 5.75, 95 % CI: 1.71 to 19.34) in a NMA including 31 RCTs and 6,623 patients of all ages. No statistically significant differences in delirium frequency were observed across all treatment comparisons in a NMA including 18 RCTs and 3,652 patients. The authors concluded that granisetron plus dexamethasone increases the risk of arrhythmia.
Table: Emetogenic Potential of Intravenous and Oral Antineoplastic Agents
Emetic Risk Without Prophylaxis
High-risk (greater than 90 % frequency of emesis)*
AC combination defined as either doxorubicin or epirubicin with cyclophosphamide
Moderate-risk (30 - 90 % frequency of emesis)*
Aldesleukin > 12 - 15 million IU/m2
Low-risk (10 - 30 % frequency of emesis)
Amisfostine ≤ 300 mg
Fludarabine (oral and intravenous)
Minimal-risk (less than 10 % frequency of emesis)*
*Proportion of patients who experience emesis in the absence of effective antiemetic prophylaxis
Note: National Comprehensive Cancer Network guidelines on antiemesis lists the emetogenic potential of additional cancer drugs; these guidelines are available at the following web address (free registration required): http://www.nccn.org/clinical.asp.
Source: NCCN Clinical Practice Guidelines in Oncology. Guidelines for Supportive Care. Antiemesis. Version 3.2008. Jenkintown, PA; NCCN; 2008. (Updated version: 1.2012; Fort Washington, PA: NCCN)
|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:|
|Other CPT codes related to this CPB:|
|77371 - 77425||Radiation treatment delivery|
|96401 - 96549||Chemotherapy administration|
|HCPCS codes covered if selection criteria are met:|
|J1260||Injection, dolasetron mesylate, 10 mg|
|J1453||Injection, fosaprepitant, 1 mg|
|J1626||Injection, granisetron HCl, 100 mcg|
|J2405||Injection, ondansetron HCl, per 1 mg|
|J2469||Injection, palonosetron HCl, 25 mcg|
|HCPCS codes related to High Emetic Risk Without Prophylaxis (greater than 90% frequency of emesis):|
|J8530||Cyclophosphamide, oral, 25 mg|
|J8700||Temozolomide, oral, 1 mg|
|J9000||Injection, doxorubicin HCl, 10 mg|
|J9050||Injection, carmustine, 100 mg [> 250mg/m2]|
|J9070||Cyclophosphamide, 100 mg [> 1,500 mg/m2]|
|J9130||Dacarbazine, 100 mg|
|J9178||Injection, epirubicin HCl, 2 mg|
|J9230||Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg|
|J9320||Injection, streptozocin, 1 g|
|Q2050||Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg|
|S0182||Procarbazine HCl, oral, 50 mg|
|HCPCS codes related to Moderate Emetic Risk Without Prophylaxis (30-90% frequency of emesis):|
|J0207||Injection, amifostine, 500 mg [> 300]|
|J0594||Injection, busulfan, 1 mg [> 4 mg/d]|
|J8510||Busulfan; oral, 2 mg [> 4 mg/d]|
|J8560||Etoposide, oral, 50 mg|
|J8600||Melphalan, oral, 2 mg [> 50 mg/m2]|
|J8610||Methotrexate, oral, 2.5 mg [250 - > 1,000 mg/m2]|
|J8700||Temozolomide, oral, 5 mg|
|J9000||Injection, doxorubicin HCl, 10 mg|
|J9015||Injection, aldesleukin, per single use vial [Interleukin-2] [> 12-15 million units/m2]|
|J9017||Injection, arsenic trioxide, 1 mg|
|J9025||Injection, azactidine, 1 mg|
|J9045||Injection, carboplatin, 50 mg|
|J9050||Injection, carmustine, 100 mg [< 250mg/m2]|
|J9060||Injection, cisplatin, powder or solution, per 10 mg [< 50 mg/m2]|
|J9070||Cyclophosphamide, 100 mg [< 1,500 mg/m2]|
|J9098||Injection, cytarabine liposome, 10 mg [> 1 g/m2]|
|J9100||Injection, cytarabine, 100 mg [> 1 g/m2]|
|J9120||Injection, dactinomycin, 0.5 mg|
|J9150||Injection, daunorubicin, 10 mg|
|J9151||Injection, daunorubicin citrate, liposomal formulation, 10 mg|
|J9178||Injection, epirubicin HCl, 2 mg|
|J9206||Injection, irinotecan, 20 mg|
|J9208||Injection, ifosfamide, 1 g|
|J9211||Injection, idarubicin HCl, 5 mg|
|J9245||Injection, melphalan HCI, 50 mg [> 50 mg/m2]|
|J9250||Methotrexate sodium, 5 mg [250 - > 1,000 mg/m2]|
|J9260||Methotrexate sodium, 50 mg [250 - > 1,000 mg/m2]|
|J9263||Injection, oxaliplatin, 0.5 mg [> 75 mg/m2]|
|Q2050||Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg|
|S0178||Lomustine, oral, 10 mg|
|HCPCS codes related to Low Emetic Risk Without Prophylaxis (10-30% frequency of emesis):|
|J0207||Injection, amifostine, 500 mg [< 300 mg]|
|J8520||Capecitabine, oral, 150 mg|
|J8521||Capecitabine, oral, 500 mg|
|J8560||Etoposide, oral, 50 mg|
|J8610||Methotrexate, oral, 2.5 mg [> 50 mg/m2 < 250 mg/m2]|
|J8700||Temozolomide, oral, 5 mg|
|J8705||Topotecan, oral, 0.25 mg|
|J9000||Injection, doxorubicin HCl, 10 mg [liposomal]|
|J9041||Injection, bortezomib, 0.1 mg|
|J9055||Injection, cetuximab, 10 mg|
|J9098||Injection, cytarabine liposome, 10 mg [low dose] [100-200 mg/m2]|
|J9100||Injection, cytarabine, 100 mg [low dose] [100-200 mg/m2]|
|J9171||Injection, docetaxel, 1 mg|
|J9181||Injection, etoposide, 10 mg|
|J9185||Injection, fludarabine phosphate, 50 mg [oral]|
|J9190||Injection, fluorouracil, 500 mg|
|J9201||Injection, gemcitabine HCl, 200 mg|
|J9250||Methotrexate sodium, 5 mg [> 50 mg/m2 < 250 mg/m2]|
|J9260||Methotrexate sodium, 50 mg [> 50 mg/m2 < 250 mg/m2]|
|J9264||Injection, paclitaxel protein-bound particles, 1 mg|
|J9265||Injection, paclitaxel, 30 mg|
|J9267||Injection, paclitaxel, 1 mg|
|J9268||Injection, pentostatin, 10 mg|
|J9280||Injection, mitomycin, 5 mg|
|J9291||Mitomycin, 40 mg|
|J9293||Injection, mitoxantrone HCI, per 5 mg|
|J9305||Injection, pemetrexed, 10 mg|
|J9307||Injection, pralatrexate, 1 mg|
|J9315||Injection, romidepsin, 1 mg|
|J9328||Injection, Temozolomide, 1 mg [Temodar]|
|J9340||Injection, thiotepa, 15 mg|
|J9351||Injection, topotecan, 0.1 mg|
|J9355||Injection, trastuzumab, 10 mg|
|Q2050||Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg|
|HCPCS codes related to Minimal Emetic Risk Without Prophylaxis (< 10% frequency of emesis):|
|J0594||Injection, busulfan, 1 mg|
|J1190||Injection, dexrazoxane HCl, per 250 mg|
|J8510||Busulfan, oral, 2mg|
|J8565||Gefitinib, oral, 250 mg|
|J8600||Melphalan, oral, 2 mg [low-dose]|
|J8610||Methotrexate, oral, 2.5 mg [< 50 mg/m2]|
|J9010||Injection, alemtuzumab, 10 mg|
|J9020||Injection, asparaginase, not otherwise specified, 10,000 units|
|J9035||Injection, bevacizumab, 10 mg|
|J9040||Injection, bleomycin sulfate, 15 units|
|J9065||Injection, cladribine, per 1 mg|
|J9185||Injection, fludarabine phosphate, 50 mg|
|J9212||Injection, interferon alfacon-1, recombinant, 1 mcg|
|J9213||Injection, interferon alfa-2A, recombinant, 3 million units|
|J9214||Injection, interferon alfa-2B, recombinant, 1 million units|
|J9215||Injection, interferon alfa-N3, (human leukocyte derived), 250,000 IU|
|J9228||Injection, ipilimumab, 1 mg|
|J9245||Injection, melphalan HCI, 50 mg [oral low-dose]|
|J9250||Methotrexate sodium, 5 mg [< 50 mg/m2]|
|J9260||Methotrexate sodium, 50 mg [< 50 mg/m2]|
|J9300||Injection, gemtuzumab ozogamicin, 5 mg|
|J9302||Injection, ofatumumab, 10 mg|
|J9306||Injection, pertuzumab, 1 mg|
|J9310||Injection, rituximab, 100 mg|
|J9357||Injection, valrubicin, intravesical, 200 mg|
|J9360||Injection, vinblastine sulfate, 1 mg|
|J9370||Vincristine sulfate, 1 mg|
|J9390||Injection, vinorelbine tartrate, per 10 mg|
|S0088||Imatinib, 100 mg|
|S0172||Chlorambucil, oral, 2 mg|
|S0176||Hydroxyurea, oral, 500 mg|
|Other HCPCS codes related to this CPB:|
|A9153||Multiple vitamins, with or without minerals and trace elements, oral, per dose, not otherwise specified|
|C8957||Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump|
|J1240||Injection, dimenhydrinate, up to 50 mg|
|J2550||Injection, promethazine HCl, up to 50 mg|
|J3250||Injection, trimethobenzamide HCl, up to 200 mg|
|J3415||Injection, pyridoxine HCl, 100 mg|
|Q0083 - Q0085||Chemotherapy administration|
|Q0162||Ondansetron 1 mg, oral, FDA-approved presecription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen|
|Q0166||Ganisetron HCl, 1 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen|
|Q0169||Promethazine HCl, 12.5 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen|
|Q0180||Dolasetron mesylate, 100 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen|
|S0091||Ganisetron HCl, 1 mg (for circumstances falling under the Medicare statute, use Q0166)|
|S0119||Ondansetron , oral, 4 mg (for circumstances falling under the medicare statute, use Q0162)|
|S0174||Dolasetron mesylate, oral, 50 mg (for circumstances falling under the Medicare statute, use Q0180)|
|S9351||Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and visits coded separately), per diem|
|S9370||Home therapy, intermittent antiemetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem [covered for high or moderate emetic risk only]|
|ICD-10 codes covered if selection criteria are met:|
|B20||Human immunodeficiency virus [HIV] disease|
|O21.0 - O21.9||Excessive vomiting in pregnancy [when clinical signs of dehydration are present or nausea and vomiting have persisted more than 3 weeks and criteria A,B, and C are met]|
|R11.0||Nausea [when criteria are met]|
|R11.10||Vomiting, unspecified [cyclical]|
|R11.11||Vomiting without nausea [when criteria are met]|
|R11.12||Projectile vomiting [when criteria are met]|
|R11.2||Nausea with vomiting, unspecified [when criteria are met]|
|T45.1X5+||Adverse effect of antineoplastic and immunosuppressive drugs [not covered for Anzemet]|
|T66.xxx+||Radiation sickness, unspecified [nausea or vomiting secondary to total body irradiation]|
|Z51.0||Encounter for antineoplastic radiation therapy [for total body radiation when oral antiemetic therapy has failed or is contraindicated]|
|Z51.11 - Z51.12||Encounter for antineoplastic chemotherapy and immunotherapy [for total body radiation when oral antiemetic therapy has failed or is contraindicated]|
|ICD-10 codes not covered for indications listed in the CPB:|