38243
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
2.08
Facility
$101.54
Non-Facility
$101.54
Documentation Required
- For MDS sideroblastic phenotypes: documentation of sideroblastic phenotype if ESA + G-CSF is being considered.
- For neonatal hemolytic disease: documentation that neonate is ≥7 days old, hematocrit at level requiring transfusion, and an inappropriate reticulocyte response (Reticulocyte Production Index < 1) — Donato et al. (2009) used these criteria to start EPO.
- For primary myelofibrosis: documentation of transfusion dependence status, baseline hemoglobin, baseline serum erythropoietin (EPO) level (when available), and other predictive factors (female sex, leukocyte count, ferritin) that relate to response likelihood per Hernandez-Boluda et al. (2017).
- For preterm/low birth-weight infant use: gestational age and timing of EPO initiation (early < 8 days vs late 8–28 days), RBC transfusion history, details of iron supplementation (dose), and neurodevelopmental follow-up data where relevant (trials referenced specific ages and outcomes).
Key Coverage Criteria
- Anemia due to chronic kidney disease (CKD) - for treatment in members with pretreatment hemoglobin less than 10 g/dL;
- Epoetin alfa (Epogen/Procrit) or epoetin alpha-epbx (Retacrit) is medically necessary for any of the following indications when criteria are met:
- Requires Precertification: Precertification of erythropoiesis stimulating agents (Aranesp, Epogen, Procrit, Retacrit, Mircera) is required of all Aetna participating providers and members in applicable plan designs.
- D46.0 - D46.Z — Myelodysplastic syndrome
- D47.4 — Osteomyelofibrosis
- D63.1 — Anemia in chronic kidney disease (peginesatide section)
20 Active Policies
AETNA-CPB-0190 — Stem Cells for Hematopoietic Cell Transplant
AETNA-CPB-0614 — Huntington's Disease
ANTHEM-MP-A047560 — TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
ANTHEM-MP-A070096 — TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
ANTHEM-MP-A053844 — TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Related Codes
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