Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A55639 (Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A55639: Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions (Billing and Coding, effective 2025-11-27)
- Covered ICD-10-CM codes
- 564
- 9 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 7
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A63.0 | — |
| B07.0 | — |
| B07.8 | — |
| B07.9 | — |
| B27.00 | — |
| B27.01 | — |
| B27.02 | — |
| B27.09 | — |
| D47.3 | — |
| D47.Z1 | — |
| D59.0 | — |
| D59.10 | — |
| D59.11 | — |
| D59.12 | — |
| D59.13 | — |
| D59.19 | — |
| D68.311 | — |
| D68.32 | — |
| D68.4 | — |
| D69.0 | — |
| D69.3 | — |
| D69.41 | — |
| D69.42 | — |
| D69.49 | — |
Procedure codes: J9190 (Injection, Fluorouracil, 500 Mg), J9215 (Injection, Interferon, Alfa-N3, (Human Leukocyte Derived), 250,000 Iu), J9260 (Injection, Methotrexate Sodium, 50 Mg), J9312 (Injection, Rituximab, 10 Mg), Q5115 (Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg), Q5119 (Injection, Rituximab-Pvvr, Biosimilar, (Ruxience), 10 Mg), Q5123 (Injection, Rituximab-Arrx, Biosimilar, (Riabni), 10 Mg).
Coverage indications, limitations and medical necessity
This LCD addresses the coverage for chemotherapy agents based on the patient’s condition, the appropriateness of the dose and route of administration, based on the clinical condition, medical necessity and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition.
• Per this LCD, chemotherapy agents may be covered if reasonable and medical necessity is met
AND
• the drug is FDA approved
AND
• listed in the NCCN Clinical Practice Guidelines in Oncology (NCCN) with the specific ICD-10 diagnosis (that is being treated) for the drug/agent.
• the chemotherapy agent must be listed Category 1 or 2A in NCCN,
• the chemotherapy agent must be utilized per the NCCN Recommended Use (order or combination).
• If the medically accepted indications are listed in one of the other Medicare approved compendia (Micromedex DrugDex as Class I, Class IIa, or Class IIb; American Hospital Formulary Service -Drug Information (AHFS) narrative text is “supportive”; Clinical Pharmacology narrative text is “supportive”; or Lexi-Drugs is listed as “Use Off-Label” and rated as “evidence level A”). A use is not medically accepted if the indication appears in the Medicare approved compendia as: NCCN as Category 3; Micromedex DrugDex as Class III; AHFS narrative text is “not supportive”; Clinical Pharmacology narrative text “not supportive”; or Lexi-Drugs is listed as “use: Unsupported”.
Summary of evidence (opening)
A compendium is a listing of U.S. Food and Drug Administration (FDA) approved drugs and biologics. In some cases, compendia specialize in a particular subset of drugs, such as those used for anti-cancer treatment. Compendia include a summary of how each drug works in the body, as well as information for health care practitioners about proper dosing and whether the drug is recommended or endorsed for use in treating a specific disease. The compendia employ various rating and recommendation systems that may not be readily cross-walked from compendium to compendium.
As a practical matter, WPS GHA is aware of the broad availability and use of the NCCN guidelines and compendia in oncology clinical practice. While the CMS Pub. 100-02 Medicare Benefit Policy Manual , Chapter 15, Covered Medical and Other Health Services, Section 50, Drugs and Biologicals instructions regarding compendia do not give exclusive status to any one of the named compendia, WPS GHA finds that NCCN is more commonly cited by oncology practitioners and providers who seek coverage for chemotherapy. With that in mind, unlabeled uses of chemotherapy are covered, as noted above in Coverage Guidance. This is to assist the provider in real-time coverage that is in accordance with a compendium.
The contractor may also consider individual cases with provided published peer reviewed literature if the claim denies and the provider feels the treatment is medically necessary.
The development and coverage guidelines in this policy were based on a review of pertinent medical literature, Medicare regulations, policies from other Medicare contractors, the Medicare approved compendia, and discussions with appropriate specialists.
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2017-09-16
- Current revision effective
- 2023-11-30
- Last reviewed by the contractor
- 2023-10-26
- MCD version
- 15
Other related documents: A55641 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L37205 cover?
This LCD addresses the coverage for chemotherapy agents based on the patient’s condition, the appropriateness of the dose and route of administration, based on the clinical condition, medical necessity and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L37205 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L37205?
The companion billing and coding article A55639 lists 564 ICD-10-CM codes in 9 groups that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L37205?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.