J0885, Injection, epoetin alfa, (for non-esrd use), 1000 units
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
- Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
- Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
- Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
- Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
- Procedure codes listed are for general reference and may not be all-inclusive.
Key Coverage Criteria
- ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
- ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
- ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
- Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
- Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
20 Active Policies
CGS-L34356, Erythropoiesis Stimulating Agents (ESA)
J15
A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)
J5
WPS-L34633, Erythropoiesis Stimulating Agents (ESAs)
J8
PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents
JJ
NGS-L40333, Erythropoiesis Stimulating Agents
JK
PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents
JM
BCBSIL-RX502.061, Oncology Medications
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSMT-RX502.061, Oncology Medications
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSNM-RX502.061, Oncology Medications
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSOK-RX502.061, Oncology Medications
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
Related Codes
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