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Snapshot of the Word file:"LCD for ZOLEDRONIC ACID (DL27257)_LCD for ZOLEDRONIC ACID (DL27257)Please note: This is a Future LCD. Please note:".doc LCD for ZOLEDRONIC ACID (DL27257) Please note: This is a Future LCD. Please note: This is a Draft policy. Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor. Contractor Information Contractor Nameback to top Palmetto GBA Contractor Numberback to top 00880 Contractor Typeback to top Carrier LCD Information LCD ID Numberback to top DL27257 LCD Titleback to top ZOLEDRONIC ACID Contractor's Determination Numberback to top ZA.0908 AMA CPT / ADA CDT Copyright Statementback to top CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policyback to top Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy, Chapter 15, Section 50, 50.1, 50.2, 50.3, 50.4.1, 50.4.2, 50.4.3 and 50.4.5 outlines coverage for drugs and biologicals. Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing, Chapter 17, Section 20, 20.1 and 40 outlines payment allowance limits for drugs and biologicals and discarding of same. Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 13. Section 13.1.3, 13,3-13.5.4, 13.6-13.7.2, Local Coverage Determinations. Primary Geographic Jurisdictionback to top South Carolina Oversight Regionback to top Region IV Projected Determination Effective Dateback to top For services performed on or after 09/01/2008 Original Determination Ending Dateback to top Revision Effective Dateback to top Revision Ending Dateback to top Indications and Limitations of Coverage and/or Medical Necessityback to top Intravenous Zoledronic acid is currently available under the brand names Zometa® and Reclast®. Zometa® (J3487) is indicated for the treatment of:
Reclast® (J3488) is indicated for treatment of:
Intravenous zoledronic acid is covered for patients with disabling osteoporosis who meet the following criteria: 1. An axial bone mass measurement T-score below -2.5, and one of the following: Aggressive, rapidly progressive osteoporosis with unrelenting pain resulting in impaired ambulation
2. Documented allergy to shellfish and/or salmon derivatives, 3. Failed a trial of calcitonin therapy, 4. Intolerance of oral bisphosphonate therapy due to medical or surgical conditions including but not limited to:
5. Patient has failed an acceptable response to a 6 month trial of oral bisphosphonates, or because the degree of severity of osteoporosis does not medically warrant an oral trial of bisphosphonates. The World Health Organization defines osteoporosis as a bone density or bone mass that exceeds 2.5 standard deviations (SD) below peak normal mass in healthy adults aged 18-30 years. SD from the mean peak bone mass is termed the “T” score. Thus, a T score of the lumbar spine or hip at least 2.5 SD below the norm defines the condition of osteoporosis. Coverage Topicback to top Chemotherapy (Outpatient) Doctor Office Visits Coding Information Bill Type Codes:back to topContractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. |