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Printer Friendly Version Interferon-alpha-n3 (Alferon- N®)

Interferon-alpha-n3 (Alferon- N®)

DESCRIPTION

Interferon alphas are naturally occuring 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-n3 (Alferon-N®), derived using recombinant DNA technology, shows activity similar to the endogenous human interferon alphas.

FDA APPROVED INDICATIONS

Interferon alpha-n3 (Alferon-N®) is indicated to treat refractory or recurring external condylomata acuminata in patients who are 18 years of age or older. (revised 9-12-2006)

IDENTIFICATION

Generic Name: Interferon-alpha-n3
Brand Name: Alferon-N®

POLICY

Interferon-alpha-n3 (Alferon-N®) is considered medically necessary for condylomata cuminata (Ano-genital warts).

POLICY EXCEPTIONS

None

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, CPT code 51720, 90782, 96400, 96445 added, ICD-9 procedure code 96.49, 99.28, 99.29 (Peritoneal instillation of INF), 99.29 [IM or SC injection of interferon (Specify as Interferon-alpha-n3 or Alferon-N)] added

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

5/1/2002: Type of Service and Place of Service deleted, Code Reference section updated, CPT codes 90782 and 96400 description revised, CPT code 96445 and ICD-9 procedure code 99.29 (Peritoneal instillation of INF) deleted, CPT code 11900, 11901 added covered codes, ICD-9 diagnosis code 078.11 added, HCPCS J9215 added, non-covered codes table added, CPT code 51720 and ICD-9 procedure code 96.49 moved to non-covered, ICD-9 diagnosis code 051.0-051.2, 052.0-053.9, 054.0-054.9, 070.20-070.33, 078.19, 078.5, 079.3, 079.4, 147.0-147.9, 151.0-151.9, 154.0-154.9, 157.0-157.9, 158.0, 162.0-162.9, 170.0-170.9, 171.0-171.9, 172.0-173.9, 174.0-174.9, 175.0-175.9, 180.1, 180.8, 180.9, 183.0, 184.4, 185, 188.0-188.9, 189.0, 189.1, 189.3, 190.1, 190.3, 190.6, 190.9, 191.9, 195.0, 197.0, 197.5, 197.6, 197.8, 198.0, 198.1, 198.2, 198.4, 198.5, 198.6, 198.81, 198.82, 198.89, 201.0-201.9, 202.10-202.28, 202.80-202.98, 203.00-203.01, 204.00-204.01, 204.10-204.11, 205.00-205.01, 206.00-206.01, 208.00-208.01, 230.0, 230.2, 230.4, 230.9, 231.2, 232.5, 232.9, 233.0, 233.1, 233.3, 233.4, 233.7, 233.9, 234.0, 234.8, 236.7, 237.5, 238.7, 239.0, 288.0-288.9, 340, 571.40-571.49, 702.0, 748.1, 771.1, 999.0, 999.3, V02.61, V08 added non-covered codes

8/15/2005: Code Reference section updated, CPT code 90782 deleted covered codes, non-covered codes table deleted, CPT code 51720 deleted non-covered codes, ICD-9 procedure code 96.49 deleted non-covered codes, ICD-9 diagnosis code code 051.0-051.2, 052.0-053.9, 054.0-054.9, 070.20-070.33, 078.19, 078.5, 079.3, 079.4, 147.0-147.9, 151.0-151.9, 154.0-154.9, 157.0-157.9, 158.0, 162.0-162.9, 170.0-170.9, 171.0-171.9, 172.0-173.9, 174.0-174.9, 175.0-175.9, 180.1, 180.8, 180.9, 183.0, 184.4, 185, 188.0-188.9, 189.0, 189.1, 189.3, 190.1, 190.3, 190.6, 190.9, 191.9, 195.0, 197.0, 197.5, 197.6, 197.8, 198.0, 198.1, 198.2, 198.4, 198.5, 198.6, 198.81, 198.82, 198.89, 201.0-201.9, 202.10-202.28, 202.80-202.98, 203.00-203.01, 204.00-204.01, 204.10-204.11, 205.00-205.01, 206.00-206.01, 208.00-208.01, 230.0, 230.2, 230.4, 230.9, 231.2, 232.5, 232.9, 233.0, 233.1, 233.3, 233.4, 233.7, 233.9, 234.0, 234.8, 236.7, 237.5, 238.7, 239.0, 288.0-288.9, 340, 571.40-571.49, 702.0, 748.1, 771.1, 999.0, 999.3, V02.61, V08 deleted non-covered codes

03/13/2006: Coding updated. CPT4 2006 revisions added to policy.

9/12/2006: Revised FDA approved indications. Removed investigational, off-label, and dosing information.

12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions.

SOURCE(S)

Fact and Comparisons, July 1996

American Hospital Formulary Services, 1998

Hayes Medical Technology Directory, July 1996

USPDI, 1998

Alferon-N® Prescribing Information (added 9-12-2006)

CODE REFERENCE

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

Covered Codes

Code Number	Description
CPT-4
11900	Injection, intralesional; up to and including seven lesions (added 5-1-2002)
11901	Injection, intralesional; more than seven lesions (added 5-1-2002)
96400	Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia (Specify as Interferon-alpha-n3 or Alferon-N®) (deleted 12-31-2005)
96401	Chemotherapy administration, subcutaneous or intramuscular, non-hormonal anti-neoplastic (Specify as Interferon-alpha-n3 or Alferon-N®) (New 12-31-2005)
96402	Chemotherapy administration, subcutaneous or intramuscular, hormonal anti-neoplastic (Specify as Interferon-alpha-n3 or Alferon-N®) (New 12-31-2005)
ICD-9 Procedure
99.28	Injection or infusion of biological response modifier [BRM] as an antineoplastic agent (Specify as Interferon-alpha-n3 or Alferon-N®)
99.29	Injection or infusion of other therapeutic or prophylactic substance (Specify as Interferon-alpha-n3 or Alferon-N®)
ICD-9 Diagnosis
078.11	Condyloma acuminatum (added 5-1-2002)
HCPCS
J9215	Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 IU (added 5-1-2002) (description revised 1-1-2009)

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