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Interferon alphas are naturally occurring glycoproteins which stimulate or regulate a wide range of biologic responses such as interfering with viral multiplication processes (anti-viral), inhibiting tumor growth (antiproliferative), activating the immune system or modifying the immune response (immunomodulatory effects), and stimulating specialization of cells (differentiation-inducing effects). Interferon alpha-2a (Roferon-A®), derived using recombinant DNA technology, shows activity similar to the endogenous human interferon alphas.
FDA APPROVED INDICATIONS
Interferon alpha-2a (Roferon-A®) is indicated for the treatment of chronic hepatitis C and hairy cell leukemia and AIDS-related Kaposi’s sarcoma in patients who are 18 years of age or older. It is also indicated for chronic phase, Philadelphia chromosome positive chronic myelogenous leukemia (CML) patients who are minimally pretreated (within 1 year of diagnosis).
Related medical policy -
Prior authorization is required.
Interferon alpha-2a (Roferon-A®) is considered medically necessary for patients 18 years of age or older with hairy cell leukemia, AIDS-related Kaposi's sarcoma, and in patients with Philadelphia chromosome positive chronic myelogenous leukemia within 1 year of diagnosis.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
7/1997: Date originally issued
4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Prior Authorization and Managed Care Requirements deleted
2/15/2002: Investigational definition added
4/30/2002: Type of Service and Place of Service deleted. Code Reference section updated. CPT codes 51720 and 96445 deleted. CPT codes 90782 and 96400 description revised. ICD-9 Procedure code 96.49 deleted. ICD-9 Procedure code 99.28 and 99.29 (Peritoneal instillation of INF deleted) description revised.
8/2/2002: ICD-9 diagnosis code 042 moved to non-covered, ICD-9 diagnosis code range 176.0-176.9 description clarified
11/27/2002: Policy section revised, Code Reference section updated, ICD-9 diagnosis code 154.9 deleted
10/28/2005: Code Reference section updated. Covered CPT-4 code 90782 deleted. Covered ICD-9 diagnosis code 152.0-152.9, 155.0-155.2, 162.2-162.9, 197.0, 197.8 deleted; ICD-9 diagnosis codes 189.2-189.9 added; revised description: 140.0-149.9, 189.0-189.9, 230.9, 233.3; detail code range: 140.0-149.9, 150.0-150.9, 153.0-153.9, 154.0-154.8, 157.0-157.9, 160.0-160.9, 161.0-161.9, 170.0-170.9, 172.0-172.9, 173.0-173.9, 176.0-176.9, 188.0-188.9, 189.0-189.9, 191.0-191.9, 200.00-200.08, 200.10-200.88, 202.00-202.08, 202.10-202.18, 202.20-202.28, 202.30-202.38, 202.40-202.48, 202.50-205.58, 202.60-202.68, 202.80-202.88, 202.90-202.98, 203.00-203.01, 204.10-204.11, 205.00-205.91, . Covered HCPCS code S0145 added. Non-covered Codes table deleted. Non-covered CPT-4 code 51720 deleted. Non-covered ICD-9 procedure code 96.49 deleted. Non-covered ICD-9 diagnosis code 042, 051.0-051.9, 053.0-053.9, 054.0-054.9, 070.20-070.33, 078.11, 078.19, 078.5, 079.3, 079.4, 151.0-151.9, 158.0-158.9, 171.0-171.9, 174.0-174.9, 175.0-175.9, 180.0-180.9, 184.4, 185, 189.2-189.9, 190.1, 190.3, 190.6, 190.9, 197.6, 198.4, 198.81, 201.0-201.9, 204.00-204.01, 206.00-206.01, 208.00-208.01, 228.00-228.09, 230.2, 231.2, 233.0, 233.1, 233.4, 234.0, 234.8, 238.7, 340, 571.40-571.49, 702.0, 771.1, 999.0, 999.3, V02.61, V08 deleted
03/13/2006: Coding updated. CPT4 2006 revisions added to policy.
09/06/2006: FDA approved indications and policy section revised. Removed investigational, off-label uses, and dosing information.
9/13/2007: Code reference section updated per the annual ICD-9 updates effective 10-1-2007.
9/11/2008: Code reference section updated per the annual ICD-9 updates effective 10-1-2008.
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added.
04/01/2014: Policy title changed from "Interferon-alpha-2a (Roferon-A®)" to "Interferon alpha-2a (Roferon-A®)." Policy description updated regarding FDA approved indications. Policy statement updated to add AIDS-related Kaposi's sarcoma as a covered indication.
Fact and Comparisons, July 1996
American Hospital Formulary Services, 1998
Hayes Medical Technology Directory, July 1996
Lexi-Comp Online (added 09-06-2006)
Roferon-A Prescribing Information (added 09-06-2006)
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.