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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-2b (Intron-A®), derived using recombinant DNA technology, shows activity similar to the endogenous human interferon alphas.
FDA APPROVED INDICATIONS
Generic Name: Interferon alpha-2b
Related medical policy -
Prior Authorization is required.
Interferon alpha-2b (Intron-A®) is considered medically necessary for the following disease states:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
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
2/14/2002: Investigational definition added
9/3/2002: Code Reference section updated, CPT codes 51720 and 96445 deleted, ICD-9 procedure codes 96.49 and 99.28 deleted
3/25/2003: Policy section revised, "Adjunct therapy for malignant melanoma" and "Soft tissue Carcinoma" deleted, Code Reference section updated
10/24/2005: Code Reference section updated,Code ranges added, CPT codes 90782 and 90784 deleted from covered codes, ICD9 Procedure code 99.28 added to covered codes, ICD9 Diagnosis codes 070.22, 070.23, 070.32, 189.8, 189.9, 197.5, 198.1, 198.89, 200.10 - 200.88, 202.30 - 202.38, 202.50 - 202.58, 202.60 - 202.68, 202.80 -202.88,202.90 -202.98, 205.00, 205.01, 205.20, 205.21, 205.30, 205.31, 205.80, 205.81, 205.90, 205.91, 223.3, 230.9, 233.3, 232.5, 232.9, 233.9 and 236.7 added to covered codes, ICD9 Diagnosis codes 070.20, 152.0 -152.9, 155.0 - 155.2, 156.0 - 156.9, 162.2 - 162.9, 154.2, 154.3, 183.9, 184.0, 184.1, 184.2, 184.41, 187.1, 187.4, 187.7, 187.9, 190.0, 190.1, 190.2, 190.3, 190.5, 190.6, 190.9, 197.7, 189.1, 202.10 - 202.18, 202.20 - 202.28, 205.11 deleted from covered codes, ICD9 Diagnosis code 202.40 - 202.48 placed in numerical order under covered codes, ICD9 Diagnosis codes 070.22, 070.23, 070.32 , 070.33, 189.0 - 189.9, 200.00 - 200.08, 202.00 - 202.08, 202.40 - 202.48 description revised, HCPCS covered code J9214 description revised, all non-covered codes removed .
03/13/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy.
10/29/2006: Dosing and off-label information removed
11/3/2006: Coding reference updated. Deleted ICD-9 codes 070.44, 070.54, 140.0-149.9, 152.0-152.9, 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, 183.0, 188.0-188.9, 189.0-189.9, 191.0-191.9, 197.5, 198.0, 198.1, 198.2, 198.5, 198.6, 200.00-200.08, 200.10-200.88, 202.01-202.08, 202.30-202.38, 202.41-202.48, 202.50-202.58, 202.60-202.68, 202.80-202.88, 202.90-202.98, 204.10, 204.11, 205.00-205.91, 223.3, 230.0, 230.4, 230.9, 232.3, 232.5, 232.9, 233.7, 233.9, 236.7, 237.5, 238.4, and 259.2
9/11/2008: Annual ICD-9 updated applied
01/01/2009: BCBSMS information added along with fax # 601-664-5004.
04/01/2014: FDA Approved Indications updated with treatment information. Removed deleted CPT code 96400 from the Code Reference section.
08/31/2015: Medical policy revised to add ICD-10 codes. Removed ICD-9 procedure code 99.29 from the Code Reference section.
05/27/2016: Policy number L.5.01.441 added. Policy Guidelines updated to add medically necessary and investigative definitions.
11/01/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
Fact and Comparisons, July 1996
American Hospital Formulary Services, 1998
Hayes Medical Technology Directory, July 1996
Intron A® Prescribing Information
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.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.