April 16, 2010 –
Last night President Obama signed the Continuing Extension Act of 2010 (H.R. 4851), into law, reinstating Medicare physician payments to where they were on March 31 and again postponing the 21.3 percent cut that was supposed to take effect in 2010. This most recent extension of 2009 payment rates will continue through the end of May, and will be applied retroactively to all physician services provided to Medicare patients in April. The legislation passed the Senate at about 5:45 pm by a bipartisan vote of 59-38, and subsequently passed the House of Representatives shortly after 8:00 pm by a bipartisan vote of 289-112.
The hold on processing April claims that the Centers for Medicare & Medicaid Services (CMS) had placed to avoid implementing the payment cut technically expired on April 15, but because Congressional action was so imminent, we do not believe many claims were actually processed at the lower payment rates. Any claims paid that reflected the 21.3 percent cut will be reprocessed automatically without any action required from physicians.
The Society thanks all members who took part in the recent Advocacy Campaign that successfully helped urge the Congress to restore physician payment rates.
Abraham Mittelman, MD
NYSSMOH, President
Congress Passes Another Short Term Extention of the 2009 Medicare Physician Payment Rate to Restore 21 Percent Cut
Petition to Stop Cancer Care Cuts
Members are encourage to place copies of a petition aimed at asking our representatives in government to stop the continued cuts to Medicare at your front desk and in each physician’s exam room. More information can also be obtained by going to http://nyssmoh.us1.list-manage.com/track/click?u=c1baa62bcce8234f03f15b2e7&id=d6ff2b1ac2&e=38bb34b435
You can also complete the Petition on line at the following link:
http://nyssmoh.us1.list-manage.com/track/click?u=c1baa62bcce8234f03f15b2e7&id=14e8c8f4b9&e=38bb34b435
Please join us in signing a petition to ask our elected officials to stop the cancer care cuts. We have the best cancer care in the world, but it is now endangered by the continual government slashing of cancer care payments. Health care reform needs to address the cancer care crisis.
Joined others in signing a petition that will be sent to policymakers. Please follow the link below to read the Stop Cancer Care Cuts Petition at http://nyssmoh.us1.list-manage.com/track/click?u=c1baa62bcce8234f03f15b2e7&id=228fc9ebdd&e=38bb34b435 , and add your name to show your support for the future of cancer care in our country.
Thank You
Abraham Mittelman, MD
NYSSMOH, President
You can also complete the Petition on line at the following link:
http://nyssmoh.us1.list-manage.com/track/click?u=c1baa62bcce8234f03f15b2e7&id=14e8c8f4b9&e=38bb34b435
Please join us in signing a petition to ask our elected officials to stop the cancer care cuts. We have the best cancer care in the world, but it is now endangered by the continual government slashing of cancer care payments. Health care reform needs to address the cancer care crisis.
Joined others in signing a petition that will be sent to policymakers. Please follow the link below to read the Stop Cancer Care Cuts Petition at http://nyssmoh.us1.list-manage.com/track/click?u=c1baa62bcce8234f03f15b2e7&id=228fc9ebdd&e=38bb34b435 , and add your name to show your support for the future of cancer care in our country.
Thank You
Abraham Mittelman, MD
NYSSMOH, President
A Letter From Dr. Silver
January 11, 2010
Dear Colleagues:
I'd like to tell you that the randomized, double blind placebo control study using a JAK2 inhibitor for the treatment primary myelofibrosis in myelofibrosis related to PV is now open at Cornell. We would be happy to evaluate your patients for this medication. Results were presented at ASH this year. The Incyte drug does represent a significant advance for the treatment of some patients with massive splenomegaly. Please contact any of our leukemia doctors at 212-746-2098.
Best regard for the New Year.
Sincerely,
Richard T. Silver, MD
Past President NYSSMOH
Dear Colleagues:
I'd like to tell you that the randomized, double blind placebo control study using a JAK2 inhibitor for the treatment primary myelofibrosis in myelofibrosis related to PV is now open at Cornell. We would be happy to evaluate your patients for this medication. Results were presented at ASH this year. The Incyte drug does represent a significant advance for the treatment of some patients with massive splenomegaly. Please contact any of our leukemia doctors at 212-746-2098.
Best regard for the New Year.
Sincerely,
Richard T. Silver, MD
Past President NYSSMOH
Erythropoiesis Stimulating Agents - Incorrect Denials
Attention Members:
The NYSSMOH Board of Directors has contacted the Medical Director of National Government Services (Medicare) regarding the issue of incorrect denials for Erythropoiesis (see below) beginning November 2009. We have been advised that this issue will be corrected by Friday, December 11, 2009. We are also told that no action is needed by the provider and that Medicare will reprocess all claims that have denied incorrectly.
Please contact NYSSMOH Administrator Florence Madonia (845-986-3295 or fmbilling@yahoo.com ) if you continue to received denials after Friday, December 11th.
Thank you,
NYSSMOH Board of Directors
The NYSSMOH Board of Directors has contacted the Medical Director of National Government Services (Medicare) regarding the issue of incorrect denials for Erythropoiesis (see below) beginning November 2009. We have been advised that this issue will be corrected by Friday, December 11, 2009. We are also told that no action is needed by the provider and that Medicare will reprocess all claims that have denied incorrectly.
Please contact NYSSMOH Administrator Florence Madonia (845-986-3295 or fmbilling@yahoo.com ) if you continue to received denials after Friday, December 11th.
Thank you,
NYSSMOH Board of Directors
Attention Part B Medicare providers who bill Erythropoiesis Stimulating Agents to National Government Services:
National Government Services has identified an issue with edit 638A based on the Local Coverage Determination Erythropoiesis Stimulating Agents L25211. It has been identified that claims are denying inappropriately with reason codes 029 or 481, These are non-covered services because this is not deemed a 'medical necessity' by the payer.We are working to correct this issue, and expect it to be resolved by mid-December 2009. All claims that have been incorrectly denied will be adjusted by National Government Services. Providers do not need to take any action at this time.Thank you for visiting the National Government Services Web site!National Government Services encourages all Web site users to provide feedback regarding ways to improve our Web site. The ForeSee Results (pop-up) survey is an easy mechanism for providers to use to let us know how we can best serve you. Your comments play a large role in the enhancements that are made to the National Government Services Web site.National Government Services, Inc.Corporate Communications
Doctors On Healthcare Reform
The following article was posted in the Wall Street Journal and includes quotes by NYSSMOH past president Seymour M. Cohen, MD
Doctors from across the country were invited to the White House on Oct. 5, but the president did most of the talking. Medical professionals are being ignored or vilified more often than consulted in the current health-care reform debate. To broaden the discussion, the Committee to Reduce Infection Deaths invited 16 highly regarded physicians to convene at the Grand Hyatt in New York City on Oct. 19 to reflect on the current legislative proposals. Here's what they had to say on four key issues.
OCTOBER 28, 2009, 7:34 P.M. EDoctors on Health-Care Reform 'Government is in the process of duplicating everything that managed care did for the last 15 years that was reviled by everybody.'By BETSY MCCAUGHEY
Government-Imposed Treatment GuidelinesDr. Jeffrey Borer, cardiologist, named to Castle Connolly's "America's Top Doctors": "What's the impact of guidelines on the doctor-patient relationship? Guidelines step in between the doctor and the patient. If it's necessary to respond to guidelines rather than what you see, feel and hear when you're evaluating a person, then perhaps you're going to do something that isn't really the right thing. There really isn't an average patient. Every person that you see with a medical problem has some unusual or unique characteristic and this often has to be considered in dealing with the problem."
Dr. David Fields, obstetrician and gynecologist, Lenox Hill Hospital, New York: "They tend to forbid better-than-average medical care; guidelines are always average medical care . . . they tend to cramp the physician who can do better than average."
Dr. Borer: "One of the more common problems that people have as they get older is a disease called aortic stenosis. . . . [W]e can relieve that aortic stenosis with an operation with really very acceptable safety, low mortality rates . . . if that 85-year-old cannot walk down the street because he or she is too breathless to do so . . . or feels light-headed or could faint and break a hip . . . then there is really a very good justification for offering the therapy."
Dr. Richard Amerling, nephrologist, Beth Israel Medical Center, New York: "The example that you give of valve surgery in an 85-year-old is just not going to happen under [White House health care adviser] Ezekiel Emanuel. He's going to just say that that's a nonstarter. That person has outlived their useful years, no matter how long they could live beyond that."
Dr. Borer: "What we're hearing from the president's medical advisers is that what we have is good enough and we really shouldn't be wanting or expecting any more."
Dr. Seymour Cohen, oncologist, named to "America's Top Doctors": "When we went to medical school, people used to die at 66, 67 and 68. Medicare paid for two or three years. Social Security paid for two or three years. We're the bad guys. We're responsible for keeping people alive to 85. So we're now going to try to change health care because people are living too long. It just doesn't make very good sense to me."
Shifting Resources From Specialty to Primary CareDr. Cohen: "Let's talk about specialization for a moment. . . . We don't go to our general attorney when we have a patent problem, but they're telling us to do this now in medicine. We have different types of engineers, even journalists. There's a financial writer, there's a sportswriter . . . . Now in health care we're telling everybody, 'you just go to the guy who's your general doc. He's going to know everything and maybe we'll find a specialist for you if the panel decides maybe you're sick enough to need a specialist.' It really doesn't make sense at all."
Dr. Jeffrey Moses, interventional cardiologist, named to "America's Top Doctors": "If you have heart failure or heart attack or coronaries in general in the hospital you need to be treated by a cardiologist. Study after study shows that . . . when you have an illness and you want to have an accurate diagnosis and the most up-to-date and accurate treatment, you want a specialist."
Patient PrivacyDr. Samuel Guillory, ophthalmologist, refractive and orbital surgery, named to Castle Connolly's "New York's Top Doctors": "We're being asked by the executive branch . . . to break the code with patients and deliver all their records into electronic medical records . . . ."
Cost-Cutting MethodsDr. Fields: "Government is in the process of duplicating everything that managed care did for the last 15 years that was reviled by everybody and which we fought very hard to overcome, The courts finally said 'You can't have withholds, you can't pay people to deny care. You can't have gag rules.' The government is in the process of doing all that. Massachusetts is about to establish capitation [a fixed payment remitted at regular intervals to a medical provider] as the rule of the state. Capitation was the wort thing that ever happened to medical care."
Dr. Joel Kassimir, dermatologist, Mt. Sinai Hospital, New York: "We're now being told by physicians advising the president that we take the Hippocratic Oath too seriously."
Dr. Tracy Pfeifer, plastic surgeon, president, New York Regional Society of Plastic Surgeons: "When physicians graduate from medical school we take an oath, the Hippocratic Oath, to do no harm to our patients. It's a very important philosophy to us and we uphold it and hold it very dear to our hearts. Plato, another philosopher, used to say things like 'Those with a poor physical constitution should be allowed to die. The weak and the ill-constituted shall perish.' These government programs that are being proposed I think are very scary in the sense that physicians could be induced to violate the Hippocratic Oath.
"There's a limit to how much of a financial penalty each individual practitioner is going to be able to bear. . . . If the patient is sitting in the examination room with us and they're wondering, 'Is the doctor not ordering a test for me because he's going to get penalized if he does it?' This is a major, major problem for patients and physicians alike."
Ms. McCaughey is chairman of the Committee to Reduce Infection Deaths and a former Lt. Governor of New York State. For a complete transcript of the physicians' meetings, visit www.defendyourhealthcare.us.
Doctors from across the country were invited to the White House on Oct. 5, but the president did most of the talking. Medical professionals are being ignored or vilified more often than consulted in the current health-care reform debate. To broaden the discussion, the Committee to Reduce Infection Deaths invited 16 highly regarded physicians to convene at the Grand Hyatt in New York City on Oct. 19 to reflect on the current legislative proposals. Here's what they had to say on four key issues.
OCTOBER 28, 2009, 7:34 P.M. EDoctors on Health-Care Reform 'Government is in the process of duplicating everything that managed care did for the last 15 years that was reviled by everybody.'By BETSY MCCAUGHEY
Government-Imposed Treatment GuidelinesDr. Jeffrey Borer, cardiologist, named to Castle Connolly's "America's Top Doctors": "What's the impact of guidelines on the doctor-patient relationship? Guidelines step in between the doctor and the patient. If it's necessary to respond to guidelines rather than what you see, feel and hear when you're evaluating a person, then perhaps you're going to do something that isn't really the right thing. There really isn't an average patient. Every person that you see with a medical problem has some unusual or unique characteristic and this often has to be considered in dealing with the problem."
Dr. David Fields, obstetrician and gynecologist, Lenox Hill Hospital, New York: "They tend to forbid better-than-average medical care; guidelines are always average medical care . . . they tend to cramp the physician who can do better than average."
Dr. Borer: "One of the more common problems that people have as they get older is a disease called aortic stenosis. . . . [W]e can relieve that aortic stenosis with an operation with really very acceptable safety, low mortality rates . . . if that 85-year-old cannot walk down the street because he or she is too breathless to do so . . . or feels light-headed or could faint and break a hip . . . then there is really a very good justification for offering the therapy."
Dr. Richard Amerling, nephrologist, Beth Israel Medical Center, New York: "The example that you give of valve surgery in an 85-year-old is just not going to happen under [White House health care adviser] Ezekiel Emanuel. He's going to just say that that's a nonstarter. That person has outlived their useful years, no matter how long they could live beyond that."
Dr. Borer: "What we're hearing from the president's medical advisers is that what we have is good enough and we really shouldn't be wanting or expecting any more."
Dr. Seymour Cohen, oncologist, named to "America's Top Doctors": "When we went to medical school, people used to die at 66, 67 and 68. Medicare paid for two or three years. Social Security paid for two or three years. We're the bad guys. We're responsible for keeping people alive to 85. So we're now going to try to change health care because people are living too long. It just doesn't make very good sense to me."
Shifting Resources From Specialty to Primary CareDr. Cohen: "Let's talk about specialization for a moment. . . . We don't go to our general attorney when we have a patent problem, but they're telling us to do this now in medicine. We have different types of engineers, even journalists. There's a financial writer, there's a sportswriter . . . . Now in health care we're telling everybody, 'you just go to the guy who's your general doc. He's going to know everything and maybe we'll find a specialist for you if the panel decides maybe you're sick enough to need a specialist.' It really doesn't make sense at all."
Dr. Jeffrey Moses, interventional cardiologist, named to "America's Top Doctors": "If you have heart failure or heart attack or coronaries in general in the hospital you need to be treated by a cardiologist. Study after study shows that . . . when you have an illness and you want to have an accurate diagnosis and the most up-to-date and accurate treatment, you want a specialist."
Patient PrivacyDr. Samuel Guillory, ophthalmologist, refractive and orbital surgery, named to Castle Connolly's "New York's Top Doctors": "We're being asked by the executive branch . . . to break the code with patients and deliver all their records into electronic medical records . . . ."
Cost-Cutting MethodsDr. Fields: "Government is in the process of duplicating everything that managed care did for the last 15 years that was reviled by everybody and which we fought very hard to overcome, The courts finally said 'You can't have withholds, you can't pay people to deny care. You can't have gag rules.' The government is in the process of doing all that. Massachusetts is about to establish capitation [a fixed payment remitted at regular intervals to a medical provider] as the rule of the state. Capitation was the wort thing that ever happened to medical care."
Dr. Joel Kassimir, dermatologist, Mt. Sinai Hospital, New York: "We're now being told by physicians advising the president that we take the Hippocratic Oath too seriously."
Dr. Tracy Pfeifer, plastic surgeon, president, New York Regional Society of Plastic Surgeons: "When physicians graduate from medical school we take an oath, the Hippocratic Oath, to do no harm to our patients. It's a very important philosophy to us and we uphold it and hold it very dear to our hearts. Plato, another philosopher, used to say things like 'Those with a poor physical constitution should be allowed to die. The weak and the ill-constituted shall perish.' These government programs that are being proposed I think are very scary in the sense that physicians could be induced to violate the Hippocratic Oath.
"There's a limit to how much of a financial penalty each individual practitioner is going to be able to bear. . . . If the patient is sitting in the examination room with us and they're wondering, 'Is the doctor not ordering a test for me because he's going to get penalized if he does it?' This is a major, major problem for patients and physicians alike."
Ms. McCaughey is chairman of the Committee to Reduce Infection Deaths and a former Lt. Governor of New York State. For a complete transcript of the physicians' meetings, visit www.defendyourhealthcare.us.
New Incyte Drug for Treatment
I thought you would be interested to learn that we have the new Incyte drug for the treatment of patients with large spleens in primary myelofibrosis. This is a randomized trial between the drug and a placebo. You can refer patients to any of us including Gail Roboz, Eric Feldman, Ellen Ritchie, Usuma Georgis, or me. The contact number is (212) 746-2098.
Best regards,
Richard T. Silver, M.D.
Professor of MedicineWeill Cornell Medical College
Past President, NYSSMOH
Best regards,
Richard T. Silver, M.D.
Professor of MedicineWeill Cornell Medical College
Past President, NYSSMOH
"The War on Specialists" -Wall Street Journal
In President Obama's Washington, medical specialists are slightly more popular than the H1N1 virus. Compared to bread-and-butter primary care doctors, specialists cost more to train and make more use of expensive procedures and technology—and therefore cost the government more money. Even so, the quiet war Democrats are waging on specialists is astonishing.
From Senate Finance Chairman Max Baucus's health-care bill to changes the Administration is pushing in Medicare, Democrats are systematically attacking specific medical fields like cardiology and oncology. With almost no scrutiny, they're trying to engineer a "cheaper" system so that government can afford to buy health care for all—even if the price is fewer and less innovative ways of extending and improving lives.
FOR THE FULL ARTICLE LINK BELOW
http://online.wsj.com/article_email/SB10001424052748704471504574443472658898710-lMyQjAxMDA5MDAwOTEwNDkyWj.html
From Senate Finance Chairman Max Baucus's health-care bill to changes the Administration is pushing in Medicare, Democrats are systematically attacking specific medical fields like cardiology and oncology. With almost no scrutiny, they're trying to engineer a "cheaper" system so that government can afford to buy health care for all—even if the price is fewer and less innovative ways of extending and improving lives.
FOR THE FULL ARTICLE LINK BELOW
http://online.wsj.com/article_email/SB10001424052748704471504574443472658898710-lMyQjAxMDA5MDAwOTEwNDkyWj.html
Phase II study Evaluating Tamibarotene
July 16, 2009
Dear Colleagues:
NorthShore University Hospital is participating in a Phase II study for adult patients with relapsed or refractory acute promyelocytic leukemia (APL) who have been previously treated with ATRA & Arsenic Trioxide. The trial is evaluating Tamibarotene, an orally administered synthetic retinoid. In vitro studies show that Tamibarotene does not substantially bind to CRABP, suggesting possible therapeutic efficacy in patients with ATRA-resistant APL.
If you have any patients that might benefit from this study or would like further information, please call my office at 516-734-8959.
Sincerely,
Steven L. Allen
Associate Chief, Division of Hematology
NorthShoreUniversityHospital
MonterCancerCenter
Dear Colleagues:
NorthShore University Hospital is participating in a Phase II study for adult patients with relapsed or refractory acute promyelocytic leukemia (APL) who have been previously treated with ATRA & Arsenic Trioxide. The trial is evaluating Tamibarotene, an orally administered synthetic retinoid. In vitro studies show that Tamibarotene does not substantially bind to CRABP, suggesting possible therapeutic efficacy in patients with ATRA-resistant APL.
If you have any patients that might benefit from this study or would like further information, please call my office at 516-734-8959.
Sincerely,
Steven L. Allen
Associate Chief, Division of Hematology
NorthShoreUniversityHospital
MonterCancerCenter
**URGENT Immediate Action Needed!**
Urgent! Immediate Action Needed!
NYSSMOH strongly urges all members to complete the Community Oncology Alliance (COA) Components of Care Study.
CMS has released the 2010 Medicare Physician Fee Schedule. It contains the 21.5% cut to all physician-related payments. It eliminates consultation codes. And the real surprise is a 6% additional cut to medical oncology.
That’s correct — an additional cut of 6% to medical oncology.
The oncologists own (AMA) data was used by CMS to arrive at these cuts. Every practice should complete and return the Components of Care Survey so we have data to refute this. We need to send out the results of the Components of Care Survey to the Congress, Administration, and the press.
Additionally, this is not a final rule — we have a comment period. In short, we need accurate, realistic data or your practice is facing large cuts next year effective 1/1/10.
The link below will direct you to the COA website.
Components of Care Study
Again, NYSSMOH strongly urges all members to complete the Components of Care Survey and forward this email on to your colleagues.
NYSSMOH strongly urges all members to complete the Community Oncology Alliance (COA) Components of Care Study.
CMS has released the 2010 Medicare Physician Fee Schedule. It contains the 21.5% cut to all physician-related payments. It eliminates consultation codes. And the real surprise is a 6% additional cut to medical oncology.
That’s correct — an additional cut of 6% to medical oncology.
The oncologists own (AMA) data was used by CMS to arrive at these cuts. Every practice should complete and return the Components of Care Survey so we have data to refute this. We need to send out the results of the Components of Care Survey to the Congress, Administration, and the press.
Additionally, this is not a final rule — we have a comment period. In short, we need accurate, realistic data or your practice is facing large cuts next year effective 1/1/10.
The link below will direct you to the COA website.
Components of Care Study
Again, NYSSMOH strongly urges all members to complete the Components of Care Survey and forward this email on to your colleagues.
Intravenous Vs Oral Drug Questions & Answers
Disclaimer: The answers to these questions were prepared by National Government Services, to assist the provider community in understanding the coverage and reimbursement for oral and parenteral drugs. These responses reflect NGS’s understanding and implementation of CMS’ instructions, and may or may not reflect the interpretations of other contractors or agencies reviewing claims.
We have received many questions regarding CMS’ policy on the medical necessity and payment for intravenous (IV) preparations of drugs when an oral preparation of the same drug is available and in common use. The following Q&As may provide guidance for correct billing in situations when both preparations of a drug are available.
Q:If an oral anti-emetic drug fails to prevent intra- or post-treatment chemotherapy induced nausea and vomiting (CINV), would an intravenous anti-emetic drug administered at the time of the next treatment session be considered medically necessary?
A:If the oral anti-emetic drug was chosen appropriately and administered in an adequate dosage and failed, we would allow the intravenous form during subsequent treatments. Such claims may be subject to medical review.
Q:Would reimbursement be contingent upon the response to the intravenous anti-emetic medication as compared to the response to the previous oral anti-emetic therapy?
A:No, the reimbursement is not dependent on the result. However, future use of the intravenous medication would require at least a better response to the intravenous anti-emetic than was achieved with the oral formulation.
Q:Would subsequent intravenous treatments be covered based upon a poor initial response to the oral formulation and an improved subsequent response to the intravenous formulation? That is, does the provider need to re-establish that the oral anti-emetic is still ineffective after the initial failure and before each start of the intravenous drug?
A:The patient does not need to fail the oral form with each course of therapy. Subsequent IV courses would be covered.
Q:If a patient has a positive response to intravenous treatment after failure of the oral preparation, does that support medical necessity of the intravenous formulation for that patient only, or for all similar patients?
A:Medical necessity is supported only for the individual patient. Because the intravenous form was necessary in one patient, that does not provide clinical evidence that the IV form will be necessary in all such patients.
Q:If a patient has taken oral anti-emetics prior to presenting for treatment and still experiences pre-treatment nausea, would the provider be reimbursed for intravenous administration of additional anti-emetics at that time?
A:Yes, if the nausea prevented the administration of the additional dose in the oral form. The inability to take oral medication at the time of treatment is considered a medically necessary reason to administer intravenous preparations.
Q:If the IV form of an anti-emetic is medically necessary, would concomitant prophylactic Benadryl and Decadron also be covered if administered intravenously?
A:No, not necessarily. The parenteral administration of any particular drug in place of its oral formulation would not be covered unless it was medically necessary. If the patient were on intravenous anti-emetics without concomitant nausea and/or vomiting, and there was no other medically necessary indication for the use of parenteral Benadryl or Decadron, then the parenteral form of Benadryl and Decadron would not be covered.
Q:Can IV Benadryl be covered in the absence of nausea/vomiting?
A:The IV form can be covered only if the oral form was unable to be ingested or was medically contraindicated for some other reason, or if needed to treat an acute allergic reaction, or recommended in the FDA labeling for the chemotherapy drug, or the scientific medical literature for the administered chemotherapy drug documents that intravenous administration is preferred or required.
Q:Can IV Decadron be covered in the absence of nausea/vomiting?
A:The IV form can be covered only if the oral form was unable to be ingested or was medically contraindicated for some other reason, or if needed to treat an acute allergic reaction, or recommended in the FDA labeling for the chemotherapy drug, or the scientific medical literature for the administered chemotherapy drug documents that intravenous administration is preferred or required.
Q:Under which specific circumstances, other than inability to ingest or swallow oral medications (e.g., physical obstruction of the esophagus or active nausea or vomiting) at the time of, or prior to, chemotherapy treatment can anti-emetics, antihistamines, steroids, or other medications be covered when administered intravenously? Please identify the specific conditions that would be considered “medically necessary.”
A:It is impractical to list every possible medical reason that IV medication would be necessary. It is expected that the attending clinician would be able to determine whether the reason for IV administration is medically necessary rather than for convenience, patient preference, or for financial considerations.
Q: If a patient fails on an oral anti-emetic drug, can the provider be reimbursed if a patient is administered intravenous drugs or must another, different oral drug be tried?
A:The provider may be reimbursed for using the intravenous formulation of the same drug. However, if the provider wishes to use the intravenous formulation of a different drug, then the oral formulation of that different drug must be shown to be ineffective or contraindicated before the IV form is covered.
Q: Will scientific studies of chemotherapy regimens utilizing only intravenous formulations be sufficient to document the medical necessity for IV forms of chemotherapy drugs that exist in both oral and intravenous forms?
A:If studies of chemotherapy treatment regimens were performed using only IV forms of the chemotherapy drug, then the IV form would be covered, since the oral form had not been proven to be effective. However, if studies show that both oral and IV forms are effective, then the IV vs. oral rules would apply.
Q: If the patient develops CINV after administration of an oral anti-emetic (other than Emend), can they receive IV Emend at the next treatment without having first tried oral Emend?
A:No, oral Emend may be more effective in a particular instance than other oral anti-emetics, so the oral formulation of the Emend must be tried before using the intravenous formulation.
We have received many questions regarding CMS’ policy on the medical necessity and payment for intravenous (IV) preparations of drugs when an oral preparation of the same drug is available and in common use. The following Q&As may provide guidance for correct billing in situations when both preparations of a drug are available.
Q:If an oral anti-emetic drug fails to prevent intra- or post-treatment chemotherapy induced nausea and vomiting (CINV), would an intravenous anti-emetic drug administered at the time of the next treatment session be considered medically necessary?
A:If the oral anti-emetic drug was chosen appropriately and administered in an adequate dosage and failed, we would allow the intravenous form during subsequent treatments. Such claims may be subject to medical review.
Q:Would reimbursement be contingent upon the response to the intravenous anti-emetic medication as compared to the response to the previous oral anti-emetic therapy?
A:No, the reimbursement is not dependent on the result. However, future use of the intravenous medication would require at least a better response to the intravenous anti-emetic than was achieved with the oral formulation.
Q:Would subsequent intravenous treatments be covered based upon a poor initial response to the oral formulation and an improved subsequent response to the intravenous formulation? That is, does the provider need to re-establish that the oral anti-emetic is still ineffective after the initial failure and before each start of the intravenous drug?
A:The patient does not need to fail the oral form with each course of therapy. Subsequent IV courses would be covered.
Q:If a patient has a positive response to intravenous treatment after failure of the oral preparation, does that support medical necessity of the intravenous formulation for that patient only, or for all similar patients?
A:Medical necessity is supported only for the individual patient. Because the intravenous form was necessary in one patient, that does not provide clinical evidence that the IV form will be necessary in all such patients.
Q:If a patient has taken oral anti-emetics prior to presenting for treatment and still experiences pre-treatment nausea, would the provider be reimbursed for intravenous administration of additional anti-emetics at that time?
A:Yes, if the nausea prevented the administration of the additional dose in the oral form. The inability to take oral medication at the time of treatment is considered a medically necessary reason to administer intravenous preparations.
Q:If the IV form of an anti-emetic is medically necessary, would concomitant prophylactic Benadryl and Decadron also be covered if administered intravenously?
A:No, not necessarily. The parenteral administration of any particular drug in place of its oral formulation would not be covered unless it was medically necessary. If the patient were on intravenous anti-emetics without concomitant nausea and/or vomiting, and there was no other medically necessary indication for the use of parenteral Benadryl or Decadron, then the parenteral form of Benadryl and Decadron would not be covered.
Q:Can IV Benadryl be covered in the absence of nausea/vomiting?
A:The IV form can be covered only if the oral form was unable to be ingested or was medically contraindicated for some other reason, or if needed to treat an acute allergic reaction, or recommended in the FDA labeling for the chemotherapy drug, or the scientific medical literature for the administered chemotherapy drug documents that intravenous administration is preferred or required.
Q:Can IV Decadron be covered in the absence of nausea/vomiting?
A:The IV form can be covered only if the oral form was unable to be ingested or was medically contraindicated for some other reason, or if needed to treat an acute allergic reaction, or recommended in the FDA labeling for the chemotherapy drug, or the scientific medical literature for the administered chemotherapy drug documents that intravenous administration is preferred or required.
Q:Under which specific circumstances, other than inability to ingest or swallow oral medications (e.g., physical obstruction of the esophagus or active nausea or vomiting) at the time of, or prior to, chemotherapy treatment can anti-emetics, antihistamines, steroids, or other medications be covered when administered intravenously? Please identify the specific conditions that would be considered “medically necessary.”
A:It is impractical to list every possible medical reason that IV medication would be necessary. It is expected that the attending clinician would be able to determine whether the reason for IV administration is medically necessary rather than for convenience, patient preference, or for financial considerations.
Q: If a patient fails on an oral anti-emetic drug, can the provider be reimbursed if a patient is administered intravenous drugs or must another, different oral drug be tried?
A:The provider may be reimbursed for using the intravenous formulation of the same drug. However, if the provider wishes to use the intravenous formulation of a different drug, then the oral formulation of that different drug must be shown to be ineffective or contraindicated before the IV form is covered.
Q: Will scientific studies of chemotherapy regimens utilizing only intravenous formulations be sufficient to document the medical necessity for IV forms of chemotherapy drugs that exist in both oral and intravenous forms?
A:If studies of chemotherapy treatment regimens were performed using only IV forms of the chemotherapy drug, then the IV form would be covered, since the oral form had not been proven to be effective. However, if studies show that both oral and IV forms are effective, then the IV vs. oral rules would apply.
Q: If the patient develops CINV after administration of an oral anti-emetic (other than Emend), can they receive IV Emend at the next treatment without having first tried oral Emend?
A:No, oral Emend may be more effective in a particular instance than other oral anti-emetics, so the oral formulation of the Emend must be tried before using the intravenous formulation.
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