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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 effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are
necessary for the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high
likelihood of vomiting exists. The anti-emetic drug is covered as a necessary means for administration of the
anti-neoplastic chemotherapeutic agents. Oral drugs prescribed for use with the primary drug, which enhance
the anti-neoplastic effect of the primary drug or permit the patient to tolerate the primary anti-neoplastic drug in
higher doses for longer periods, are not covered. Self-administered anti-emetics to reduce the side effects of
nausea and vomiting brought on by the primary drug are not included beyond the administration necessary to
achieve drug absorption. Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic
drugs that are used as full replacement for intravenous dosage forms of a cancer regimen under the following
conditions:
- Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as
anti-emetics;
- The oral anti-emetic must either be administered by the treating physician or in accordance with a written
order from the physician as part of a cancer chemotherapy regimen;
- Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within 2 hours
of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours
from that time;
- The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous antiemetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. Only
drugs pursuant to a physician's order at the time of the chemotherapy treatment qualify for this benefit. The
dispensed number of dosage units may not exceed a loading dose administered within two hours of the
treatment, plus a supply of additional dosage units not to exceed 48 hours of therapy. Oral drugs that are not
approved by the FDA for use as anti-emetics and which are used by treating physicians adjunctively in a
manner incidental to cancer chemotherapy are not covered by this benefit and are not reimbursable within the
scope of this benefit. It is recognized that a limited number of patients will fail on oral anti-emetic drugs.
Intravenous anti-emetics may be covered (subject to the rules of medical necessity) when furnished to patients
who fail on oral anti-emetic therapy. More than one oral anti emetic drug may be prescribed and may be
covered for concurrent use if needed to fully replace the intravenous drugs that otherwise would be
given. See the Medicare National Coverage Determinations Manual, Publication 100-03, Chapter 1, Section
110.18, for detailed coverage criteria. You can find this information in the Medicare Benefit Policy Manual
Chapter 15 - Covered Medical and Other Health Services- 50.5.4 - Oral Anti-Nausea (Anti-Emetic) Drugs.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.