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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 ESAs may be administered by intravenous or subcutaneous routes. An intravenous route is 
generally recommended for an ESRD indication. Please see the accompanying billing and coding article for 
details related to required modifier use on claims for ESA administration reporting. 
 
Coverage Criteria: (Review the Billing and Coding Article for further detail regarding documentation) 
 
    For ESRD patients on dialysis 
        Diagnosis of end stage renal disease 
        Anemia of ESRD with a Hb <10 gm/dL or a HCT < 30% at initiation of therapy 
        Most recent creatinine within the past month prior to initiation or next dosing of ESA 
        Use of an ESA that is FDA approved for this indication 
    For CKD patients NOT on dialysis 
        Anemia of CKD with a Hb < 10 g/dL or a HCT < 30% at initiation of therapy 
        Most recent creatinine within the past month prior to initiation or next dosing of ESA 
        Glomerular filtration rate (GFR) less than 45 mL/min/1.73 m2 
        Use of an ESA that is FDA approved for this indication 
 
    For patients with non-myeloid malignancies with anemia due to chemotherapy 
 
    This policy does not replace, modify or supersede existing Medicare applicable NCDs. 
        Hb level immediately prior to initiation or maintenance of ESA treatment is < 10 g/dL (or HCT is < 30%) 
        Use of an ESA that is FDA approved for this indication 
        The starting dose for ESA treatment is the recommended FDA label starting dose. 
        Maintenance of ESA therapy is the starting dose if the Hb level remains below 10 g/dL (or HCT is <30%) 
4 weeks after initiation of therapy and the rise in Hb is > 1g/dL (HCT > 3%). 
        For patients whose hemoglobin rises < 1g/dL (HCT rise < 3%) compared to pretreatment baseline over 4 
weeks of treatment and whose Hb remains < 10 g/dL afterwards (or HCT < 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 
Hb rises < 1g/dL (HCT rise < 3%) compared to pretreatment baseline by 8 weeks of treatment. 
        Continued administration of the drug is not reasonable and necessary if there is a rapid rise in Hb > 1 g/dl 
(HCT >3%) over 2 weeks of treatment unless the Hb or HCT remains below or subsequently falls to < 10 g/dL 
or 30% respectively. Continuation and reinstitution of ESA therapy must include a dose reduction of 25% from 
the previously administered dose.         ESA treatment duration for each course of chemotherapy includes the 8 weeks following the final dose of 
myelosuppressive chemotherapy in a chemotherapy regimen. 
    For patients with anemia related to AZT treatment for HIV/AIDS 
        Anemia with Hb <10 g/dL or a HCT < 30% at initiation of therapy 
        Use of an ESA that is FDA approved for this indication 
        An AZT dose < 4200 mg/week 
        An endogenous baseline pre-transfusion serum EPO (sEPO) level < 500mU/mL 
    For Peri-surgical adjuvant therapy to reduce allogenic transfusion: 
        Undergoing planned elective major hip or knee surgery 
        Presurgical anemia with Hb between 10 and 13 g/dL at least 3 weeks prior to surgery 
        Use of an ESA that is FDA approved for this indication 
        Not a candidate for autologous blood transfusion 
        Expectation for peri-operative blood loss of two units or more 
        Previous evaluation to ensure that the existing anemia is likely due to chronic disease rather than another 
reversible condition  
 
            In addition to the FDA labeled indications above, ESAs are covered for the following off-label 
indications. At this time, there is no clearly established dosing regimen for off label indications. 
 
You can find this information in the Local Coverage Determination (LCD) Erythropoiesis Stimulating Agents 
L39237. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.