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Memorial hermann healthnet providers

MEDICAL MANAGEMENT POLICY

TITLE
: Reclast® (zoledronic acid) Infusion
POLICY NUMBER: MEDM-068-2011
(Pre-Cert Required) Yes X No
EFFECTIVE DATE: 07/01/2011
REVISION DATE:
PAGE: 1 of 2
SUPERSEDES:
POLICY IN COMPLIANCE WITH:

This Medical policy is not a guarantee of benefits or coverage, nor should it be deemed as
medical advice. In the event of any conflict concerning benefit coverage, the
employer/member summary plan document (SPD) supersedes this medical policy.
DEFINITIONS:
Reclast is a bone loss infusion therapy drug. The once-yearly drug prevents
fractures.
INDICATIONS:

A. Copy of bone mineral density (BMD) studies documenting the presence of osteoporosis (T-
scores of lower than -2.5) or osteopenia (T-scores of -1 to -2.5).
B. Medical records documenting treatment failure, intolerance, or contraindication to both
alendronate and Actonel® (risedronate).
Or:
Paget's disease of bone in men and women. Patients who should be treated have evaluations in
serum alkaline phosphatase of two times higher that the upper limit of the age-specific normal
reference range, of those who are symptomatic, or those at risk for complications from their
disease.
POLICY: The recommended dose of Reclast for osteoporosis is a single 5 mg infusion given
once a year IV over no less than 15 minutes.
The recommended dose of Reclast for osteopenia (prevention of osteoporosis) in post-
menopausal women is a single 5 mg infusion given over no less than 15 minutes. The dose is
given every two years.
Diagnoses that are approved for treatment with Reclast (MHealth follows Medicare guidelines):
Treatment of osteoporosis in postmenopausal women
Prevention of osteoporosis in postmenopausal women (presence of osteopenia)
Osteoporosis in men
Glucocorticoid-induced osteoporosis
Paget's disease of the bone
MEDICAL MANAGEMENT POLICY

TITLE
: Reclast (zoledronic acid) Infusion
POLICY NUMBER: MEDM-068-2011
(Pre-Cert Required) Yes X No
EFFECTIVE DATE: 07/01/2011
REVISION DATE:
PAGE: 2 of 2
SUPERSEDES:
POLICY IN COMPLIANCE WITH:

PROCESS:

The member or provider must contact:
1. The Customer Service department to verify eligibility/benefits. 2. Medical Management to initiate a pre-authorization. 3. Provide clinical information which supports the medical necessity of the requested
CPT, HCPC CODES
:
(Note the codes below are not all-inclusive and MHealth does follow Medicare Guidelines):
J3487
Injection, Zoledronic acid (zometa), 1 mg Injection, Zoledronic acid (reclast), 1 mg Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour

Source: http://healthplan.memorialhermann.org/uploadedFiles/_Library_Files/Health_Plan/Medical_Policies/Reclast.pdf

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