Coverage Policy
The information displayed below pertains specifically to the Ambulatory Surgical Center setting of care. For information tailored to the Physician Office setting or Hospital Outpatient setting, please select the appropriate tab to the left. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Physician-administered drugs are generally covered under Medicare Part B if (1) they are reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice; (2) they are not usually self-administered; and (3) they meet the requirements for coverage of items as incident to a physician’s service. The general requirements for coverage under the “incident to” provision are that the drug be of a form that is not usually self-administered and that the drug be furnished and administered by a physician.1 Medicare has not issued a National Coverage Determination (NCD) for ALOXI®. Local Medicare contractors (Fiscal Intermediary [FI], Carrier or Part A/B Medicare Administrative Contractor [MAC]) may make coverage decisions for ALOXI®. Some local contractors have published Local Coverage Determinations (LCDs) and other coverage instruction through articles and bulletins that relate to ALOXI®. However, the absence of a published coverage policy does not mean that there is no coverage for ALOXI®.
For more information on Medicare coverage for ALOXI®, contact the Eisai Assistance Program at 1-866-61-EISAI or 1-866-61-34724.
Payor Reimbursement
As of January 2008, Medicare has been paying Ambulatory Surgery Center(ASCs) using a payment system based on the hospital OPPS. Drugs that qualify for pass-through payment under the OPPS system and are provided integral to a covered surgical procedure are paid in exactly the same manner as under OPPS. When administered in ASCs and when provided integral to a covered surgical procedure, ALOXI® is reimbursed by Medicare at Average Sales Price (ASP) plus 4%, adjusted quarterly.
Administration Services
Drug administration Current Procedural Terminology (CPT) codes may not be paid separately when performed in conjunction with certain surgical procedures based on the Global Surgery Payment rule.
1. See the Medicare Benefits Policy Manual, Chapter 15, section 50 for further information.
