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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : Interferon
Interferons are a family of naturally-occurring proteins that are produced by cells of the immune system. Three classes of interferons have been identified: alfa, beta, and gamma. Each class has different effects, though their activities overlap. Together, the interferons direct the immune system’s attack on viruses, bacteria, tumors, and other foreign substances that may invade the body. Once interferons have detected and attacked a foreign substance, they alter it by slowing, blocking, or changing its growth or function.
The following interferon procedure codes are benefits of Texas Medicaid:
The following procedure codes for Interferon may be indicated for, but are not limited to, treatment of the conditions listed below:
AIDS-related Kaposi sarcoma
Chronic hepatitis C virus Chronic myelogenous leukemia Hairy cell leukemia
Metastatic melanoma Renal cell carcinoma
Acute leukemias
AIDs-related Kaposi sarcoma Basal- and squamous-cell cancer Behcet syndrome
Bladder tumors (local use for superficial tumors) Carcinoid tumor
Chronic granulocytic leukemia Chronic hepatitis B virus Chronic hepatitis C virus Chronic myelogenous leukemia Condylomata acuminata Cutaneous T-cell lymphoma Cytolomegavirus
Essential thrombocytopenia Essential thrombocytosis Follicular lymphoma
Hairy cell leukemia Herpes simplex Hodgkin’s disease
Hypereosinophilic syndrome Melanoma
Multiple myeloma Mycosis fungoides
Non-Hodgkin’s lymphoma Ovarian and cervical carcinoma Papilloma viruses Polycythemia vera
Renal cell carcinoma Rhino viruses Varicella zoster
Chronic granulomatous disease
Malignant osteoporosis
Note: Pegylated interferons are self-administered weekly and are available through Texas Medicaid Vendor Drug Program for Medicaid fee-for-service clients.

Texas Medicaid & Healthcare Partnership
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