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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services treatment of iron deficiency anemia in patients who have intolerance or an 
unsatisfactory response to oral iron, treatment of iron deficiency anemia in patients with chronic kidney disease 
(CKD), treatment of iron deficiency anemia in patients who have non-dialysis dependent CKD. Iron deficiency 
anemia occurs when the body's red blood cell production is reduced due to low iron stores. Worldwide, iron 
deficiency anemia is the most common nutritional disorder. It is estimated that one-half of anemia cases are 
due to iron deficiencies. Iron deficiency anemia is most commonly seen in patients with certain types of cancer, 
chronic kidney disease (CKD), premenopausal women with abnormal bleeding, pregnancy, inflammatory 
bowel disease, and some gastrointestinal disorders. Iron deficiency anemia also occur in other chronic 
conditions or due to surgery. In most instances, oral iron replacement therapy should be attempted prior to 
parenteral iron administration. Some conditions, namely cancer, CKD, inflammatory bowel disease and others 
may be inappropriate to use oral iron replacement therapy. 
 
A. FOR ALL INDICATIONS: 
     1. Documentation of member having iron deficiency anemia evidenced by a laboratory report within the last 
14 days of a Hgb level of <12 g/dL AND Ferritin =100 ng/mL OR Ferritin =300 ng/mL when transferrin 
saturation (TSAT) =30%; 
AND 
     2. The member has: experienced inadequate response to a consistent trial of oral iron or has a documented 
intolerance or contraindication to oral iron therapy OR has been diagnosed with a condition in which oral iron 
is not appropriate which includes ANY of the following: (i) member is unable to tolerate gastrointestinal side 
effects of oral iron, (ii) member has a malabsorption syndrome, (iii) member has had gastric surgery that 
impairs the intestinal absorption of oral iron, (iv)member has severe or ongoing blood loss, (v) member is in 
second trimester of pregnancy with hemoglobin <10.5g, (vi) member is in third trimester of pregnancy or (v) 
member is being treated for an oncology indication 
AND 
     3. (a) The member has a documented failure or intolerance to Infed, Venofer, or Ferrlecit. 
OR 
         (b) IF BEING USED FOR CANCER OR CHEMO-RELATED ANEMIA: Prescriber attestation of 
medical necessity for requested iron preparation. AND 
4. FOR INJECTAFER OR MONOFERRIC: Documentation of member's current weight (within 
the last 30 days). 
 
All other uses of Feraheme (ferumoxytol), and Injectafer (ferric carboxymaltose) are considered 
experimental/investigational and therefore, will follow Molina's Off- Label policy. Contraindications to 
Feraheme (ferumoxytol) Monoferric (ferric derisomaltose), and Injectafer (ferric carboxymaltose) include 
hypersensitivity to the product, including inactive components. Feraheme is also contraindicated in patients 
with a history of allergic reaction to any intravenous iron product. 
 
You can find these rules in the Drug and Biologic Coverage Criteria: Iron Deficiency Anemia Agents. 
 
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.