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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 : 9.2.39.36 Amifostine

9.2.39.36
Amifostine is a benefit of Texas Medicaid for the reduction of the cumulative renal toxicity associated with administration of cisplatin in clients who have advanced ovarian cancer or non-small cell lung cancer with documentation of a creatinine clearance of 50 or less and where no other chemotherapeutic agent can be used.
Amifostine may also be used to reduce the incidence of moderate-to-severe xerostomia in clients undergoing postoperative radiation treatment for head and neck cancers where the radiation port includes a substantial portion of the parotid glands.
Amifostine may be reimbursed for the following indications:
Reduction in the incidence of xerostomia associated with postoperative radiation treatment of head and neck cancer, where the radiation port includes a substantial portion of the parotid glands
Providers must use procedure code J0207 with one of the following diagnosis codes:
 

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