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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that the following are coverage criteria for Erythropoiesis Stimulating Agents (ESA): A. For End Stage Renal Disease (ESRD) patients on dialysis
1. Diagnosis of end stage renal disease
2. Anemia of ESRD with a Hgb less than 10 gm/dL or a Hct of less than 30% at initiation of therapy
B. For chronic kidney disease patients NOT on dialysis
1. Anemia of ESRD with a Hgb less than 10 g/dL or a Hct of less than 30% at initiation of therapy
2. Serum creatinine equal to or greater than 3, creatinine clearance less than 60 ml/min, or glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2
C. For patients with non-myeloid malignancies where anemia is due to the effect of chemotherapy
1. The hemoglobin level immediately prior to initiation or maintenance of ESA treatment is
2. The starting dose for ESA treatment is the recommended FDA label starting dose, no more than 150 U/kg/3 times weekly for epoetin and 2.25 mcg/kg/1 time weekly for darbepoetin alpha. Equivalent doses may be given over other approved time periods.
3. Maintenance of ESA therapy is the starting dose if the hemoglobin level remains below 10 g/dL (or hematocrit is <30%) 4 weeks after initiation of therapy and the rise in hemoglobin is > 1g/dL (hematocrit > 3%).
4. For patients whose hemoglobin rises
5. Continued administration of the drug is not reasonable and necessary if there is a rapid rise in hemoglobin > 1 g/dl (hematocrit >3%) over 2 weeks of treatment unless the hemoglobin remains below or subsequently falls to
6. ESA treatment duration for each course of chemotherapy includes the 8 weeks following the final dose of myelosuppressive chemotherapy in a chemotherapy regimen.
D. For patients with anemia related to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) therapy for HIV/AIDS:
1. Anemia with Hgb less than 10 g/dL or a Hct of less than 30% at initiation of therapy
E. For patients with myelodysplastic syndrome
1. Myelodysplasia with less than 10% blasts
2. Pretreatment erythropoietin levels of 500 or less
3. Anemia with Hgb less than 10 g/dL or a Hct of less than 30% at initiation of therapy. If after two months of treatment, there is no significant increase in Hgb/Hct and/or a significant decrease in transfusion requirements, erythropoietin analogs therapy should be stopped.
F. Perisurgical adjuvant therapy: (epoetin alfa only) for patients who
1. Are undergoing hip or knee surgery
2. Have an anemia with a Hgb between 10 and 13 g/dL
3. Are not a candidate for autologous blood transfusion
4. Are expected to lose more than two units of blood
5. Have been evaluated to ensure that their anemia is due to chronic disease
G. For patients with anemia of chronic disease
1. Anemia with Hgb less than 10 g/dL or a Hct of less than 30% at initiation of therapy
The literature covering the use of ESAs for anemia of chronic disease is mixed, though developing. Most reported studies are small, and positive effects must be balanced with newer data that shows some patients given ESAs with anemia of cancer have shorter survival times. Currently there is evidence of patient benefit using ESA therapy to reduce transfusions for selected patients with significant refractory and symptomatic anemia who have inflammatory diseases (rheumatoid arthritis, Crohn's disease, ulcerative colitis), and hepatitis C with anemia due to the medication regimen. Until further publications show clear benefit, ESAs for anemia of other chronic diseases other than those listed above will not be covered. Use the lowest dose of an ESA that will gradually increase the Hgb concentration to the lowest level sufficient to avoid the need for red blood cell transfusion.
You can find these rules in the Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents (ESA), L34356.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.