Download Prostate Cancer – Pharmacological treatment

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Pharmaceutical
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2013-PH-0005
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Effective Date:
December 2013
Revision Date:
December 2014
Prostate Cancer – Pharmacological
treatment
Adjudication Rule
Table of content
Abstract Scope Adjudication Policy
Page 1
Page 2 Page 2
Adjudication examples
Page 3
Denial codes
Page 3
Appendices
Page 4
Approved by:
Daman
Abstract
Responsible:
Medical Strategy &
Development Department
For Members
Prostate cancer, one of the most common types of cancer in men, refers to a
cancerous growth within the prostate gland - a small gland that produces the seminal
fluid that nourishes and transports sperm. One of the treatment modalities involves
chemotherapy (and use of other drugs) to treat Cancer.
Prostate cancer drugs are covered by Daman as per policy terms and conditions, if
medically indicated.
For Medical Professionals
The goals of pharmacotherapy for prostate cancer are to induce remission, reduce
morbidity, and prevent complications. Agents used include hormone therapy,
chemotherapeutic agents, Corticosteroids etc.
Prostate cancer drugs are covered by Daman as per policy terms and conditions, if
medically indicated.
Related Adjudication Rules:
None.
Disclaimer
By accessing these Daman Adjudication Rules
(the “AR”), you acknowledge that you have read
and understood the terms of use set out in the
disclaimer below:
The information contained in this AR is intended
to outline the procedures of adjudication of
medical claims as applied by the National Health
Insurance Company – Daman PJSC (hereinafter
“Daman”). The AR is not intended to be
comprehensive, should not be used as treatment
guidelines and should only be used for the
purpose of reference or guidance for adjudication
procedures and shall not be construed as
conclusive. Daman in no way interferes with the
treatment of patient and will not bear any
responsibility for treatment decisions interpreted
through Daman AR. Treatment of patient is and
remains at all times the sole responsibility of the
treating Healthcare Provider. This AR does not
grant any rights or impose obligations on Daman.
The AR and all of the information it contains are
provided "as is" without warranties of any kind,
whether express or implied which are hereby
expressly disclaimed.
Under no circumstances will Daman be liable to
any person or business entity for any direct,
indirect, special, incidental, consequential, or
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to, or inability to use or access to, or reliance on
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This AR is subject to the laws, decrees, circulars
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Any
information provided herein is general and is not
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regulations related to the AR as enforced in the
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document governing the relationship between
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This AR is developed by Daman and is the
property of Daman and may not be copied,
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party without Daman’s express written consent.
This AR incorporates the Current Procedural
Terminology and Current Dental Terminology
(CPT® and CDT®, which is a registered
trademark of the American Medical Association
(“AMA”), and the American Dental Association
(“ADA”) respectively), and the CPT and CDT codes
and descriptions belong to the AMA. Daman
reserves the right to modify, alter, amend or
obsolete the AR at any time by providing one
month prior notice.
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Prostate Cancer – Pharmacological treatment
Scope
b.
This Adjudication Rule defines the medical
necessity for prescribing Prostate cancer drugs.
Antiandrogen tablets prevent the testosterone
in the testicles from getting to the cancer cells.
The scope of this AR is only limited to the
pharmacological treatment of Prostate cancer itself;
any other drugs, such as those related to
symptomatic treatment of prostate cancer or
complications of chemotherapy, are out of the
scope of this AR.
Anti-androgens
Examples:
Cyproterone acetate
Flutamide
Bicalutamide
Abiraterone
Medical Necessity
Used in combination with other hormone therapy to
prevent a rise in testosterone at the beginning of LHRH agonist therapy
For the palliation of symptomatic metastases and as
neoadjuvant therapy for radiation therapy.
Adjudication Policy
Eligibility / Coverage Criteria
Daman covers Prostate
cancer drugs when
medically necessary (in terms of type, frequency,
extent, site, duration and effectiveness) as per the
indications listed below and as per policy terms and
conditions.
Abiraterone
Indication - to treat late stage castration-resistant
prostate cancer before the administration of
chemotherapy.
It is used in combination with prednisone in castrationrecurrent metastatic disease prostate cancer for the
following:

as initial therapy in patients with symptomatic
disease who are not candidates for a
docetaxel-based regimen in castration
recurrent metastatic disease;

for initial treatment of asymptomatic or
minimally symptomatic patients; and

For subsequent treatment of symptomatic
disease previously treated with a docetaxelbased regimen.
Indications
1. Hormone Therapy
[3]
Prostate cancer cells rely on testosterone to help
them grow. Hormone therapy is treatment to stop
the body from producing the male hormone
testosterone.
a.
Antiandrogen therapy
LH-RH Agonists/GnRH Agonists
Luteinizing hormone-releasing hormone (LHRH)
agonists
and
gonadotropin-releasing
hormone (GnRH) agonists are hormone therapy
drugs that lower the production of testosterone
in a man's body.
Hormonal therapy is not routinely recommended
for men with prostate cancer who have a
biochemical relapse unless they have:
LH-RH Agonists/GnRH Agonists
Examples:
Goserelin
Leuprolide
Triptorelin
Degarelix
Histrelin acetate

symptomatic local disease progression, or

any proven metastases, or

PSA doubling time < 3 months.
2. Chemotherapy
Daman
covers
chemotherapy.
Medical Necessity
the
Drugs
Degarelix, goserelin acetate, histrelin acetate, leuprolide
acetate, or triptorelin pamoate is considered medically
necessary for the treatment of prostate cancer when
any of the following indications are met:
1. Clinically localized disease with intermediate
(T2b to T2c cancer, Gleason score of 7, or
prostate specific antigen (PSA) value of 10-20
ng/mL) or higher risk of recurrence; or
2. Locally advanced disease; or
3. Other
advanced, recurrent, or metastatic
disease; or
4. In combination with antiandrogen (flutamide or
bicalutamide) for locally confined stage T2b-T4
(stage B2-C) disease.
Docetaxel
[2]
Cabazitaxel
[12]
Degarelix, goserelin acetate, histrelin acetate, leuprolide
acetate or triptorelin pamoate is considered medically
necessary to shrink an enlarged prostate to an
acceptable size prior to brachytherapy, cryosurgery or
external beam radiation therapy for the treatment of
prostate cancer.
following
drugs
as
Indications
FDA approved docetaxel injection for
use in combination with prednisone for
the treatment of metastatic, androgenindependent (hormone-refractory)
prostate cancer.
Used for prostate cancer that has not
responded to hormone therapy.
Used if hormone treatment is no longer
controlling the cancer.
For use in combination with prednisone
for treatment of metastatic hormone
refractory prostate cancer previously
treated with a docetaxel-containing
regimen.
3. Bisphosphonates
[13]
Bisphosphonates will be covered when used as an
adjuvant therapy in patients with prostate cancer
at high risk of developing bone metastases.
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Prostate Cancer – Pharmacological treatment
4. Steroids
ICD code 185 - Malignant neoplasm of prostate
(principal diagnosis
Steroids will be covered for hormone refractory
prostate cancer or parallel to chemotherapy.
V58.11- Encounter for antineoplastic chemotherapy
1286-4147-001 – Docetaxel
Requirements for Coverage
How should this claim be adjudicated?
ICD and CPT codes must be coded to the highest
level of specificity.
Answer: The claim will be paid if V58.11 is coded
as the principal diagnosis and 185 is coded as the
secondary diagnosis.
Non-Coverage
Pharmacological treatment of Prostate cancer is not
covered when it does not meet medical necessity.
Denial codes
(Investigational use of any prostate cancer drug is
not considered medically necessary).
Code
Daman does not cover all those drugs for basic
plan, which are not tagged as Abu Dhabi in green
rain code list.
Payment and Coding Rules
Please apply HAAD payment rules and regulations
and relevant coding manuals for ICD, CPT, etc. [1]
Assign code V58.11, Encounter for antineoplastic
chemotherapy, as the principal diagnosis if a
patient is admitted solely for chemotherapy
administration. Assign a code for the malignancy
for prostate cancer as the secondary diagnosis.
Sequence the malignancy (primary or secondary)
as the principal diagnosis if a patient is admitted for
staging the prostate malignancy even though
chemotherapy may be administered.

AUTH-008
Inappropriate Drug Dose
CODE-010
Activity/Diagnosis inconsistence with
clinician speciality
MNEC-003
Service is not clinically indicated based
on good clinical practice
MNEC-004
Service is not clinically indicated based
on good clinical practice, without
additional supporting
diagnosis/activities.
NCOV-001
Diagnosis(es) is (are) not covered
NCOV-003
Service(s) is (are) not covered
Appendices
A. References
1. AMA editorial staff (2011-2012). Current
Procedural Terminology. 4th ed. Chicago:
American Medical Association. 373-375
Frequency of Services

Code description
Adjuvant hormonal therapy is recommended for
a minimum of 2 years in men receiving radical
radiotherapy for localised prostate cancer who
have a Gleason score of ≥ 8. [6]
2. Cancer
Research
UK.
(2012).
About
Chemotherapy
for
prostate
cancer.
Available:
http://www.cancerresearchuk.org/cancerhelp/type/prostatecancer/treatment/chemotherapy/aboutchemotherapy-for-prostate-cancer.
Last
accessed 08072013
Repeat cycles of treatment with docetaxel are
not recommended if the disease recurs after
completion
of
the
planned
course
of
chemotherapy [6]
3. Cancer Research UK. (2012). About hormone
therapy for prostate cancer. Available:
http://www.cancerresearchuk.org/cancerhelp/type/prostatecancer/treatment/hormone/about-hormonetherapy-for-prostate-cancer#pitreg.
Last
accessed 08072013
Adjudication Examples
Example 1
Question: A 51 year old male patient holding a
Regional plan, presented to the hospital with
Prostate cancer stage T2b, and was treated with
Degarelix (to shrink the prostate prior to
brachytherapy). Will Daman pay for this drug?
4. FDA. (2010). Vantas (histrelin implant).
Available:
http://www.accessdata.fda.gov/drugsatfda_
docs/label/2011/021732s013lbl.pdf.
Last
accessed 08072013.
Answer: Yes, the payment will be covered.
Example 2
Question: A 50 year old male holding a Thiqa plan
with Prostate cancer undergoes chemotherapy and
the provider bills as follows:
5. ICD-9 CM Official Guidelines for Coding and
Reporting
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Prostate Cancer – Pharmacological treatment
6. Institute for Health and Care Excellence.
(2008). NICE clinical guidelines; Prostate
cancer: Diagnosis and Treatment. Available:
http://publications.nice.org.uk/prostatecancer-cg58/guidance.
Last
accessed
08072013.
7. National Cancer Institute. (2013). Drugs
Approved for Prostate Cancer. Available:
http://www.cancer.gov/cancertopics/druginf
o/prostatecancer. Last accessed 08072013.
8. National Collaborating Centre for Cancer.
(2008). Prostate cancer; Diagnosis and
Treatment.
Available:
http://www.nice.org.uk/nicemedia/pdf/CG58
NICEGuideline.pdf. Last accessed 08072013.
9. National Comprehensive Cancer Network.
(2013). NCCN Guidelines for Patients Prostate
Cancer.
Available:
http://www.nccn.org/patients/guidelines/pro
state/index.html#34/z.
Last
accessed
23092013.
10. Prostate Cancer Foundation of Australia.
(2013). Prostate Cancer Staging and
Grading.
Available:
http://www.prostate.org.au/articleLive/page
s/Staging-and-Grading.html. Last accessed
07/10/2013.
11. Prostate Cancer UK. (2012). Prostate
Cancer.
Available:
http://prostatecanceruk.org/information/pro
state-cancer/getting-the-results.
Last
accessed 07/10/2013.
12. Sanofi-Aventis
(2010).
Highlights
of
prescribing
information;
JEVTANA
(Cabazitaxel).
Available:
http://www.accessdata.fda.gov/drugsatfda_
docs/label/2010/201023lbl.pdf.
Last
accessed 08072013.
13. The Prostate Cancer Charity Information
Team. (2011). Bisphosphonates. Available:
http://www.nhs.uk/ipgmedia/national/Prosta
te%20Cancer%20UK/Assets/Bisphosphonate
s(PCC).pdf. Last accessed 07/10/2013.
B. Revision History
Date
01-11-13
15-07-14
Change(s)
N.A
1. V 1.1
2. Disclaimer updated as per
system requirements
National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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