Appeal type: unknown
Decision: unknown

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 say that Erythropoietin stimulating agents (ESAs) are a covered benefit to treat patients who have one of the FDA approved conditions, and have either symptomatic anemia or are transfusion dependent:The Appeal Number is:1-9816521906The Appeal Number is:1-9816521906
Group A: EndStage Renal Disease (ESRD) ON DialysisGroup B: Chronic Kidney Disease (CKD) NOT on DialysisGroup C: Indications other than Renal DiseaseGroup A: End Stage Renal Disease (ESRD) ON dialysisThe likelihood of anemia associated with erythropoietin deficiency increases as renal failure progresses, because the diseased kidneys are unable to produce sufficient quantities of erythropoietin. The anemia of Chronic Renal Failure (CRF) should not be confused with the anemia of chronic disease. In the latter, inflammatory cytokines suppress the endogenous production of erythropoietin and erythropoiesis directly. Measurable levels of circulating cytokines may be found in stable dialysis patients, but, in the absence of inflammation, do not adversely affect the actionof ESAs. In patients with impaired renal function and a normochromic, normocytic anemia, it is rare for the serum erythropoietin level to be elevated. Therefore, measurement of erythropoietin levels in such patients is not likely to guide clinical decision making or ESA therapy. Anemia can develop relatively early in the course of CRF and has been associated with a serum creatinine as low as 2.0 mg/dL.The hemoglobin level prior to initiation of ESA treatment is less than 10 g/dL (or the hematocrit isless than 30%).Group B: Chronic Kidney Disease NOT on dialysisThe hemoglobin level prior to initiation of ESA treatment is less than 10 g/dL (or the hematocrit is less than 30%).Serum creatinine is greater than or equal to 3 orCreatinine clearance is less than 60 ml/min, orGlomerular filtration rate (GFR) is less than 60 mL/min/1.73 m2.This local policy defines the potential eligibility for coverage of ESAs in the treatment of anemia in patients with chronic renal failure/insufficiency. For this purpose, WPS adopts the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendation, derived largely from the NHANES III analysis. Patients with glomerular filtration rate (GFR) Grade III or higher, a GFR less than 60 ml/min/1.73m 2, should be evaluated for anemia and treated with an erythropoietic agent if appropriate and in accordance with the NKF Guidelines for Anemia of Chronic Kidney Disease.Group C: Indications other than Renal DiseaseAnemia associated with cancer and related Neoplastic conditions.This policy does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) and does not contain specific diagnosis codes related to CMSPub 100-03 Medicare National Coverage Determination (NCD) Manual, Chapter 1 -Coverage Determinations, Part 2 Section 110.21 -Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions.The hemoglobin level immediately prior to initiation or maintenance of ESA treatment is less than 10 g/dL (or the hematocrit is less than 30%).Anemia related to therapy with Zidovudine (AZT) and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) therapy for acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) must meet the coverage requirements in CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15 -Covered Medical and Other Health Services, Section -50.5.2. -Erythropoietin (EPO) (Rev. 1, 10-01-03).The hemoglobin level prior to initiation of ESA treatment is less than 10 g/dL (or the hematocrit is less than 30%).
Anemia associated with chemotherapeutic medications when medically necessary for a non-cancer diagnosis or following stem cell transplantation and associated immunosuppression.The hemoglobin level prior to initiation of ESA treatment is less than 10 g/dL (or the hematocrit is less than 30%).Myelodysplastic Syndrome (MDS)Anemia is observed in 90 percent of individuals with MDS. Those MDS patients with an endogenous erythropoietin level of less than 500 mU/mL are more likely to respond to ESA therapy.ESA therapy is indicated for patients who meet the following:Have a confirmed diagnosis ofMDS with a bone marrow biopsy,the anemia is symptomatic,there is reasonable expectancy of longer survival,therapy will end or reduce the need for transfusions,Anemia with Hgb is less than or equal to 10g/dL or HCT is less than or equal to 30%, one week before the initial injection.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.You can find this information in Medicare's Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents (ESAs) (L34633).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com