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 Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3. 
 
The rules state that 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 anti-
emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment.   
 
Only drugs pursuant to a physicians 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.  
 
You can find this information in the Medicare Benefit Policy Manual Chapter 15 Section 50.5.4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.