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Printer Friendly Version Interferon-alpha-2a (Roferon-A®)

Interferon-alpha-2a (Roferon-A®)

DESCRIPTION

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 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) (added 09-06-2006).

IDENTIFICATION

Generic Name: Interferon-alpha-2a
Brand Name: Roferon-A®

POLICY

Prior authorization is required.

Interferon-alpha-2a (Roferon-A®) is considered medically necessary for patients 18 years of age or older with chronic hepatitis C or hairy cell leukemia, and in patients with Philadelphia chromosome positive chronic myelogenous leukemia within 1 year of diagnosis (revised 09-06-2006).

For Interferon-alpha-2a (Roferon-A®) use in Chronic Hepatitis C, refer to the Chronic Hepatitis C medical policy (added 09-06-2006).

POLICY EXCEPTIONS

Cancer related diagnoses may be covered due to state and/or federal mandates.

POLICY GUIDELINES

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.

POLICY HISTORY

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.

SOURCE(S)

Fact and Comparisons, July 1996

American Hospital Formulary Services, 1998

Hayes Medical Technology Directory, July 1996

USPDI, 1998

Lexi-Comp Online (added 09-06-2006)

Roferon-A Prescribing Information (added 09-06-2006)

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Some codes may be variable and coverage will be based on the clinical indication for the service.

Covered Codes

*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section.

Code Number	Description
CPT-4
96401	Chemotherapy administration, subcutaneous or intramuscular,non-hormonal anti-neoplastic (Specify as Interferon-alpha-2a or Roferon-A®) (new 1-1-2006)
96402	Chemotherapy administration, subcutaneous or intramuscular, hormonal anti-neoplastic (Specify as Interferon-alpha-2a or Roferon-A®) (new 1-1-2006)
ICD-9 Procedure
99.28	Injection or infusion of biological response modifier [BRM] as an antineoplastic agent (Specify as Interferon-alpha-2a or Roferon-A®)
99.29	Injection or infusion of other therapeutic or prophylactic substance
ICD-9 Diagnosis
140.0, 140.1, 140.3, 140.4, 140.5, 140.6, 140.8, 140.9, 141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9, 142.0, 142.1, 142.2, 142.8, 142.9, 143.0, 143.1, 143.8, 143.9, 144.0, 144.1, 144.8, 144.9, 145.0, 145.1, 145.2, 145.3, 145.4, 145.5, 145.6, 145.8, 145.9, 146.0, 146.1, 146.2, 146.3, 146.4, 146.5, 146.6, 146.7, 146.8, 146.9, 147.0, 147.1, 147.2, 147.3, 147.8, 147.9, 148.0, 148.1, 148.2, 148.3, 148.8, 148.9, 149.0, 149.1, 149.8, 149.9	Malignant neoplasm of lip, oral cavity, and pharynx (head and neck) code range (added 11-27-2002) (147.0-147.9 added 4-30-2002 - moved to covered 11-27-2002)
150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9	Malignant neoplasm of esophagus code range (added 11-27-2002)
153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9	Malignant neoplasm of colon code range(added 11-27-2002)
154.0, 154.1, 154.2, 154.3, 154.8	Malignant neoplasm of rectum, rectosigmoid junction, and anus code range code range (added 4-30-2002) (moved to covered 11-27-2002)
157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9	Malignant neoplasm of pancreas code range (added 4-30-2002) (moved to covered 11-27-2002)
160.0, 160.1, 160.2, 160.3, 160.4, 160.5, 160.8, 160.9	Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses (head and neck) code range (added 11-27-2002)
161.0, 161.1, 161.2, 161.3, 161.8, 161.9	Malignant neoplasm of larynx (head and neck) code range (added 11-27-2002)
170.0, 170.1, 170.2, 170.3, 170.4, 170.5, 170.6, 170.7, 170.8, 170.9	Malignant neoplasm of bone and articular cartilage code range (added 4-30-2002) (Osteosarcoma) (moved to covered 11-27-2002)
172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9	Malignant melanoma of skin code range (added 4-30-2002) (moved to covered 11-27-2002)
173.0, 173.1, 173.2, 173.3, 173.4, 173.5, 173.6, 173.7, 173.8, 173.9	Other malignant neoplasm of skin of lip (Cutaneous T-cell Lymphoma, skin) code range (added 11-27-2002) (173.9 added 4-30-2002 - moved to covered 11-27-2002)
176.0, 176.1, 176.2, 176.3, 176.4, 176.5, 176.6, 176.9	Kaposi's sarcoma code range (added 4-30-2002)
183.0	Malignant neoplasm of ovary (added 4-30-2002) (moved to covered 11-27-2002)
188.0, 188.1, 188.2, 188.3, 188.4, 188.5, 188.6, 188.7, 188.8, 188.9	Malignant neoplasm of bladder code range (added 4-30-2002) (moved to covered 11-27-2002)
189.0, 189.1, 189.2, 189.3, 189.4, 189.8, 189.9	Malignant neoplasm of kidney and other urinary organs code range (moved to covered 11-27-2002) (Codes added and description revised 10-28-2005)
191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9	Malignant neoplasm of brain code range (191.0-191.8 added 11-27-2002) (191.9 added 4-30-2002 - moved to covered 11-27-2002)
197.5	Secondary malignant neoplasm of large intestine and rectum (added 4-30-2002) (moved to covered 11-27-2002)
198.0	Secondary malignant neoplasm of kidney (added 4-30-2002) (moved to covered 11-27-2002)
198.1	Secondary malignant neoplasm of other urinary organs (added 4-30-2002) (moved to covered 11-27-2002)
198.2	Secondary malignant neoplasm skin of breast (added 4-30-2002) (moved to covered 11-27-2002)
198.5	Secondary malignant neoplasm of bone and bone marrow (added 4-30-2002) (Osteosarcoma) (moved to covered 11-27-2002)
198.6	Secondary malignant neoplasm of ovary (added 4-30-2002) (moved to covered 11-27-2002)
198.82	Secondary malignant neoplasm of genital organs (added 4-30-2002) (moved to covered 11-27-2002)
198.89	Secondary malignant neoplasm of other specified sites (added 4-30-2002) (Nasopharyngeal cancer) (moved to covered 11-27-2002)
200.00, 200.01, 200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08	Reticulosarcoma (Cutaneous T-Cell Lymphoma, Non-Hodgkin's Lymphomas) code range (added 11-27-2002)
200.10, 200.11, 200.12, 200.13, 200.14, 200.15, 200.16, 200.17, 200.18, 200.20, 200.21, 200.22, 200.23, 200.24, 200.25, 200.26, 200.27, 200.28, 200.30, 200.31, 200.32, 200.33, 200.34, 200.35, 200.36, 200.37, 200.38, 200.40, 200.41, 200.42, 200.43, 200.44, 200.45, 200.46, 200.47, 200.48, 200.50, 200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 200.57, 200.58, 200.60, 200.61, 200.62, 200.63, 200.64, 200.65, 200.66, 200.67, 200.68, 200.70, 200.71, 200.72, 200.73, 200.74, 200.75, 200.76, 200.77, 200.78, 200.80, 200.81, 200.82, 200.83, 200.84, 200.85, 200.86, 200.87, 200.88	Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue (Non-Hodgkin's Lymphomas) (added 11-27-2002) (code range description revised 10-1-2007), 200.30-200.78 (new 10-1-2007)
202.00, 202.11, 202.12, 202.13, 202.14, 202.15, 202.16, 202.17, 202.08	Nodular lymphoma (Non-Hodgkin's Lymphomas) (added 11-27-2002)
202.10, 202.11, 202.12, 202.13, 202.14, 202.15, 202.16, 202.17, 202.18	Mycosis fungoides (Cutaneous T-cell lymphoma, Non-Hodgkin's Lymphomas) (added 4-30-2002) (moved to covered 11-27-2002)
202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28	Mycosis fungoides (Cutaneous T-cell lymphoma, Non-Hodgkin's Lymphomas) (added 4-30-2002) (moved to covered 11-27-2002)
202.30, 202.31, 202.32, 202.33, 202.34, 202.35, 202.36, 202.37, 202.38	Malignant histiocytosis (Non-Hodgkin's Lymphomas) (added 11-27-2002)
202.40, 202.41, 202.42, 202.43, 202.44, 202.45, 202.46, 202.47, 202.48	Leukemic reticuloendotheliosis (Hairy Cell Leukemia, Non-Hodgkin's Lymphomas) (added 4-30-2002)
202.50, 202.51, 202.52, 202.53, 202.54, 202.55, 202.56, 202.57, 205.58	Letterer-Siwe disease (Non-Hodgkin's Lymphomas) (added 11-27-2002)
202.60, 202.61, 202.62, 202.63, 202.64, 202.65, 202.66, 202.67, 202.68	Malignant mast cell tumors (Non-Hodgkin's Lymphomas) (added 11-27-2002)
202.70, 202.71, 202.72, 202.73, 202.74, 202.75, 202.76, 202.77, 202.78	Peripheral T-cell lymphoma (new 10-1-2007)
202.80, 202.81, 202.82, 202.83, 202.84, 202.85, 202.86, 202.87, 202.88	Other malignant lymphomas (Non-Hodgkin's Lymphomas) (added 4-30-2002) (moved to covered 11-27-2002)
202.90, 202.91, 202.92, 202.93, 202.94, 202.95, 202.96, 202.97, 202.98	Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue (Non-Hodgkin's Lymphomas) (added 11-27-2002)
203.00-203.01	Multiple myeloma code range (added 4-30-2002) (moved to covered 11-27-2002)
204.10-204.11	Chronic lymphoid leukemia code range (added 4-30-2002) (moved to covered 11-27-2002)
205.00, 205.01, 205.02, 205.10, 205.11, 205.12, 205.20, 205.21, 205.22, 205.30, 205.31, 205.32, 205.80, 208.81, 205.82, 205.90, 205.91, 205.92	Myeloid leukemia code range (added 4-30-2002) (205.02, 205.12, 205.22, 205.32, 205.82, 205.92 new 10-1-2008)
209.10	Malignant carcinoid tumor of the large intestine, unspecified portion (new 10-1-2008)
209.11	Malignant carcinoid tumor of the appendix (new 10-1-2008)
209.12	Malignant carcinoid tumor of the cecum (new 10-1-2008)
209.13	Malignant carcinoid tumor of the ascending colon (new 10-1-2008)
209.14	Malignant carcinoid tumor of the transverse colon (new 10-1-2008)
209.15	Malignant carcinoid tumor of the descending colon (new 10-1-2008)
209.16	Malignant carcinoid tumor of the sigmoid colon (new 10-1-2008)
209.17	Malignant carcinoid tumor of the rectum (new 10-1-2008)
209.24	Malignant carcinoid tumor of the kidney (new 10-1-2008)
223.3	Benign neoplasm of bladder (added 4-30-2002) (moved to covered 11-27-2002)
230.0	Carcinoma in situ of lip, oral cavity, and pharynx (added 4-30-2002) (moved to covered 11-27-2002)
230.1	Carcinoma in situ of esophagus (added 11-27-2002)
230.4	Carcinoma in situ of rectum (added 4-30-2002) (moved to covered 11-27-2002)
230.9	Carcinoma in situ of other and unspecified digestive organs, pancreas (added 4-30-2002) (moved to covered 11-27-2002) (description revised 10-28-2005)
232.5	Carcinoma in situ of skin of trunk, except scrotum (added 4-30-2002) (moved to covered 11-27-2002)
232.9	Carcinoma in situ of skin, site unspecified (added 4-30-2002) (moved to covered 11-27-2002)
233.30	Carcinoma in situ, unspecified female genital organ (new 10-1-2007)
233.7	Carcinoma in situ of bladder (added 4-30-2002) (moved to covered 11-27-2002)
233.9	Carcinoma in situ of other and unspecified urinary organs (added 4-30-2002) (moved to covered 11-27-2002)
236.7	Neoplasm of uncertain behavior of bladder (added 4-30-2002) (moved to covered 11-27-2002)
237.5	Neoplasm of uncertain behavior of brain and spinal cord (added 4-30-2002) (moved to covered 11-27-2002)
238.4	Neoplasm of uncertain behavior of polycythemia vera (added 11-27-2002)
259.2	Carcinoid syndrome (added 11-27-2002)
748.1	Malignant glioma of nose (added 4-30-2002) (moved to covered 11-27-2002)
HCPCS
J9213	Interferon, alfa-2a, recombinant, 3 million units (added 4-30-2002)
S0145	Injection, pegylated interferon alfa-2a, 180 MCG per ml (effective 7-01-2005) (code added 10-28-2005)