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Introduction Commercial Payer Prior Authorization Medicare Part D Prior Authorization Please see full Prescribing Information, including Boxed WARNINGS, for PROCRIT® (Epoetin alfa) Medicare Guideline Archives Medicare Guideline Update Table CMS 1450 / UB-04

State Medicare Guidelines / CMS 1500
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State Medicare Guidelines / CMS 1500

Colorado Printable Version


Summary - Part A  Summary - Part B  

National Coverage Determination

Local Coverage Determinations / Supporting Documentation:
MAC Part A - MAC Part B

CMS 1500 Examples
Initial Claims: Oncology 1 Subsequent Claims: Oncology 2
Nephrology 1 Nephrology 2
AZT/HIV 1 AZT/HIV 2
Surgery 1 Surgery 2
Payers

Part A
TrailBlazer Health Enterprises, LLC
Part B
TrailBlazer Health Enterprises, LLC

Carrier/FI/MAC Changes

Legal Notice: This document is presented for informational purposes only and is not intended to provide reimbursement or legal advice. Laws, regulations and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document the information may not be as current or comprehensive when you view it. Please consult with your counsel or reimbursement specialist for any reimbursement or billing questions.



Please refer to the National Coverage Determination (NCD) for additional information that may supercede the Medicare guidelines provided by your local Medicare Carrier, Fiscal Intermediary, or Medicare Administrative Contractor (MAC).



Summary - Part A - Updated August 01, 2010

For additional information on Medicare covered indications for your specific state, please see the appropriate Part A Local Coverage Determinations/Supporting Documentation which may be accessed through the link above or by clicking here - Part A.

Your state has two Medicare contractors which process claims for Part A providers. If you use WPS (formerly Mutual of Omaha), please select it now. WPS If you do not use WPS, the Medicare guideline summary is below.

Indication ICD-9-CM HCPCS Starting Labs Ending Labs GFR/Serum Creatinine Allowable Dosage Post Chemo
Cancer (chemo, non-myeloid malignancies only) 285.3 and V58.11 (or V67.2 for post-chemo)
Link		 J0885
Link		 See NCD
Link		 See NCD
Link		 SC: Not Applicable

GFR: Not Applicable		 See NCD
Link		 See NCD
Link
AIDS/AZT 042
Link		 J0885
Link		 Endogenous EPO < 500 mU/mL, AZT < 4200 mg/wk
Link		 Target HCT 36% or Hb 12 g/dL
Link		 SC: Not Applicable

GFR: Not Applicable		 Max allowable dose 400,000 units/month.
Link		 Not Applicable
Renal 285.21
Link		 J0885
Link		 HCT < 30% w/in 1 wk of initial treatment; anemia must be symptomatic
Link		 Target HCT 36%
Link		 SC: Not Stated

GFR: Not Stated		 Max allowable dose 400,000 units/month.
Link		 Not Applicable
Surgery (non-cardiac, non-vascular) 998.11
Link		 J0885
Link		 Hb between 10 and 12 g/dL w/in 1 wk of initial treatment
Link		 Target HCT 36% or Hb 12 g/dL
Link		 SC: Not Applicable

GFR: Not Applicable		 Max allowable dose 400,000 units/month.
Link		 Not Applicable

These summaries have been prepared using the Medicare guidelines. If you would like to receive the Medicare guidelines, you can call PROCRITline® at 1-800-553-3851 or you can contact the Medicare contractor directly at the web address in the State Medicare Payers box above.
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Please refer to the National Coverage Determination (NCD) for additional information that may supercede the Medicare guidelines provided by your local Medicare Carrier, Fiscal Intermediary, or Medicare Administrative Contractor (MAC).



Summary - Part B - Updated August 01, 2010

For additional information on Medicare covered indications for your specific state, please see the appropriate Medicare carrier Part B Local Coverage Determinations/Supporting Documentation which may be accessed through the link above or by clicking here - Part B.

Indication ICD-9-CM HCPCS Starting Labs Ending Labs GFR/Serum Creatinine Allowable Dosage Post Chemo
Cancer (chemo, non-myeloid malignancies only) 285.3 and V58.11 (or V67.2 for post-chemo)
Link		 J0885
Link		 See NCD
Link		 See NCD
Link		 SC: Not Applicable

GFR: Not Applicable		 See NCD
Link		 See NCD
Link
AIDS/AZT 042
Link		 J0885
Link		 Endogenous EPO < 500 mU/mL, AZT < 4200 mg/wk
Link		 Target HCT 36% or Hb 12 g/dL
Link		 SC: Not Applicable

GFR: Not Applicable		 Max allowable dose 400,000 units/month.
Link		 Not Applicable
Renal 285.21
Link		 J0885
Link		 HCT < 30% w/in 1 wk of initial treatment; anemia must be symptomatic
Link		 Target HCT 36%
Link		 SC: Not Stated

GFR: Not Stated		 Max allowable dose 400,000 units/month.
Link		 Not Applicable
Surgery (non-cardiac, non-vascular) 998.11
Link		 J0885
Link		 Hb between 10 and 12 g/dL w/in 1 wk of initial treatment
Link		 Target HCT 36% or Hb 12 g/dL
Link		 SC: Not Applicable

GFR: Not Applicable		 Max allowable dose 400,000 units/month.
Link		 Not Applicable

These summaries have been prepared using the Medicare guidelines. If you would like to receive the Medicare guidelines, you can call PROCRITline® at 1-800-553-3851 or you can contact the Medicare contractor directly at the web address in the State Medicare Payers box above.
R146
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Important Safety Information for PROCRIT® (Epoetin alfa)

WARNINGS: INCREASED MORTALITY, SERIOUS CARDIOVASCULAR EVENTS, THROMBOEMBOLIC EVENTS, STROKE and INCREASED RISK OF TUMOR PROGRESSION OR RECURRENCE

Chronic Renal Failure:
  • In clinical studies, patients experienced greater risks for death, serious cardiovascular events, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target hemoglobin levels of 13 g/dL and above.

  • Individualize dosing to achieve and maintain hemoglobin levels within the range of 10 to 12 g/dL.
Cancer:
  • ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in some clinical studies in patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers (see WARNINGS: Table 1).

  • To decrease these risks, as well as the risk of serious cardio- and thrombovascular events, use the lowest dose needed to avoid red blood cell transfusion.

  • Because of these risks, prescribers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program to prescribe and/or dispense PROCRIT® to patients with cancer. To enroll in the ESA APPRISE Oncology Program, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance.

  • Use ESAs only for treatment of anemia due to concomitant myelosuppressive chemotherapy.

  • ESAs are not indicated for patients receiving myelosuppressive therapy when the anticipated outcome is cure.

  • Discontinue following the completion of a chemotherapy course.
Perisurgery: PROCRIT® (Epoetin alfa) increased the rate of deep venous thromboses in patients not receiving prophylactic anticoagulation. Consider deep venous thrombosis prophylaxis.

(See WARNINGS: Increased Mortality, Serious Cardiovascular Events, Thromboembolic Events, and Stroke, WARNINGS: Increased Mortality and/or Increased Risk of Tumor Progression or Recurrence, INDICATIONS AND USAGE, and DOSAGE AND ADMINISTRATION.)

Please see full Prescribing Information, including Boxed WARNINGS for PROCRIT® (Epoetin alfa)

Medication Guide for PROCRIT®
Please read the Medication Guide for PROCRIT® and discuss with your doctor.

Patient Instructions for Use
Instructions if you or your caregiver has been trained to give PROCRIT® injections at home.




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CPT codes, descriptions and material only are copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use.

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