ANTINEOPLASTON THERAPY HS-183
Clinical Coverage Guideline page 1
Original Effective Date: 8/5/2010 - Revised: 8/2/2011, 8/2/2012, 8/1/2013, 8/7/2014, 7/11/2015Easy Choice Health Plan, Inc.
Harmony Health Plan of Illinois, Inc.
Missouri Care, Inc.
‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
WellCare Health Insurance of Illinois, Inc.
WellCare Health Plans of New Jersey, Inc.
WellCare Health Insurance of Arizona, Inc.
WellCare of Florida, Inc.
WellCare of Connecticut, Inc.
WellCare of Georgia, Inc.
WellCare of Kentucky, Inc.
WellCare of Louisiana, Inc.
WellCare of New York, Inc.
WellCare of South Carolina, Inc.
WellCare of Texas, Inc.
WellCare Prescription Insurance, Inc.
Windsor Health Plan
Windsor Rx Medicare Prescription Drug Plan
Antineoplaston Therapy
Policy Number: HS-183 Original Effective Date: 8/5/2010
Revised Date(s): 8/2/2011; 8/2/2012;
8/1/2013; 8/7/2014; 7/11/2015
APPLICATION STATEMENT
The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.
ANTINEOPLASTON THERAPY HS-183
Clinical Coverage Guideline page 2
Original Effective Date: 8/5/2010 - Revised: 8/2/2011, 8/2/2012, 8/1/2013, 8/7/2014, 7/11/2015DISCLAIMER
The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of current LOBs.
BACKGROUND
Originally isolated from human blood and urine by Stanislaw Burzynski, M.D., Ph.D., in Houston, Texas, antineoplastons are synthetic compounds made up of naturally occurring peptides, amino acid derivatives and organic acids. For many years, Dr. Burzynski has utilized antineoplaston therapy to treat patients with a variety of cancers. In 1991, the clinical responses in a group of patients treated with antineoplastons at the Burzynski Research Institute in Houston were reviewed by the National Cancer Institute
1.
POSITION STATEMENT Applicable To:
Medicaid – All Markets Medicare – All Markets
Antineoplaston therapy, including, but not limited to, antineoplaston A10 and AS2-1, is considered experimental and investigational for all conditions, including, but not limited to, any malignancy.
CODING
Covered CPT© Code – No applicable codes.
HCPCS Level II© Code – No applicable codes.
Non-Covered ICD-9-CM Diagnosis Codes
140.0 - 239.9 Neoplasms; malignant, benign, uncertain behavior and unspecified nature 282.41 - 282.49 Thalassemias
282.60 - 282.69 Sickle-cell disease 335.10 - 335.19 Spinal muscular atrophy V58.0 Encounter for radiotherapy V58.11 Encounter of chemotherapy V58.12 Encounter for immunotherapy Non-Covered ICD-10 Diagnosis Codes
C00.0 - C96.9 Malignant neoplasms; malignant and secondary D00.00 - D09.9 In Situ Neoplasms
D10.0 - D36.9 Benign neoplasms, except benign neuroendrocrine tumors D3A.00 - D3A.8 Benign neuroendocrine tumors
D37.01 - D48.9 Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes D49.0 - D49.9 Neoplasms of unspecified behavior
D56.0 - D56.9 Thalassemia; alpha, beta, delta-beta, minor, HPFH, unspecified D57.0 - D57.819 Sickle-cell disorders; Hb SS, Hb-C, thalassemia, other
Z51.0 - Z51.89 Encounter for other aftercare; radiation therapy, chemotherapy, immunotherapy, palliative
*Current Procedural Terminology (CPT) 2015 American Medical Association: Chicago, IL.®©
REFERENCES
1. Antineoplastons PDQA. National Cancer Institute Web site. http://www.cancer.gov/. Published March 13, 2003. Accessed July 24, 2014.
MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS
Date Action
7/11/2015, 8/7/2014, 8/1/2013, 8/2/2012 Approved by MPC. No changes.
12/1/2011 New template design approved by MPC.
8/2/2011 Approved by MPC. No changes.
