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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 say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.

The rules also say that Erythropoiesis stimulating agents (ESAs) stimulate the bone marrow to make more red
blood cells and are United States Food and Drug Administration (FDA) approved for use in reducing the need
for blood transfusion in patients with specific clinical indications. The FDA has issued alerts and warnings for
ESAs administered for a number of clinical conditions, including cancer. Published studies report a higher risk
of serious and life-threatening events associated with oncologic uses of ESAs.

ESA treatment for the anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors,
multiple myeloma, lymphoma, and lymphocytic leukemia is only reasonable and necessary under the following
specified conditions:

a. The hemoglobin level immediately prior to initiation or maintenance of ESA treatment is < 10 g/dL (or the
hematocrit is < 30%).
b. 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.
c. Maintenance of ESA therapy is the starting dose if the hemoglobin level remains below 10g/dL (or
hematocrit is < 30%) 4 weeks after initiation of therapy and the rise in hemoglobin is = 1g/dL (hematocrit =
3%);
d. For patients whose hemoglobin rises < 1g/dl (hematocrit rise < 3%) compared to pretreatment baseline
over 4 weeks of treatment and whose hemoglobin level remains < 10g/dL after the 4 weeks of treatment (or the
hematocrit is < 30%), the recommended FDA label starting dose may be increased once by 25%. Continued use
of the drug is not reasonable and necessary if the hemoglobin rises < 1g/dl (hematocrit rise < 3%) compared to
pretreatment baseline by 8 weeks of treatment.
e. Continued administration of the drug is not reasonable and necessary if there is a rapid rise in hemoglobin
> 1g/dl (hematocrit > 3%) over 2 weeks of treatment unless the hemoglobin remains below or subsequently
falls to < 10g/dL (or the hematocrit is < 30%). Continuation and reinstitution of ESA therapy must include a
dose reduction of 25% from the previously administered dose.
f. ESA treatment duration for each course of chemotherapy includes the 8 weeks following the final dose of
myelosuppressive chemotherapy in a chemotherapy regimen.

You can find more information at National Coverage Determination (NCD) for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions (110.21).

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.