Q0139 — Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Submission of medical records (e.g., lab values, chart notes, etc.) supporting the diagnosis of IDA.
- Submission of laboratory values demonstrating treatment failure to at least two of the following intravenous iron therapies: Ferrlecit® (sodium ferric gluconate complex), Infed® (iron dextran), Venofer® (iron sucrose). Note: Laboratory values should be obtained within 4 to 12 weeks following the last dose of intravenous iron in a treatment course.
- Prescriber attestation that the clinical response with Feraheme or Injectafer would be expected to be superior to the clinical response experienced with the preferred intravenous iron products (when claiming superiority-based approval).
- Prescriber attestation that the same intolerance, contraindication, or severe adverse event experienced with the preferred intravenous iron products would not be expected to occur with Feraheme or Injectafer (when claiming intolerance-based approval).
Key Coverage Criteria
- Feraheme (ferumoxytol) and Injectafer (ferric carboxymaltose) are proven for the following indication: Iron Deficiency Anemia (IDA) Without Chronic Kidney Disease (CKD) when the following criteria are met: Submission of medical records (e.g., lab values, chart notes, etc.) supporting the diagnosis of IDA; and Patient does not have CKD; and one of the following: History of failure, contraindication, or intolerance, to oral iron therapy; or Patient has severe iron deficiency in late-stage pregnanc [...]
- For continuation of therapy for IDA Without CKD (Feraheme or Injectafer): Coverage previously provided by UnitedHealthcare for Feraheme or Injectafer for the treatment of IDA based on documented history of intolerance/contraindication/severe adverse event to all three preferred intravenous iron products OR treatment failure of at least two of the three preferred intravenous iron products; Submission of recent laboratory results (within the past 4 to 12 weeks) since the last Feraheme or Injectafe [...]
- Iron Deficiency Anemia (IDA) Associated With Chronic Kidney Disease (CKD), Without End Stage Renal Disease (ESRD): Feraheme and Injectafer are medically necessary when: Diagnosis of IDA and CKD; Submission of medical records supporting diagnosis of IDA; Patient does not have ESRD; and one of the following: Patient's CKD requires hemodialysis or peritoneal dialysis treatment; OR Patient's CKD does not require hemodialysis or peritoneal dialysis treatment and History of failure, contraindication, [...]
- For continuation of therapy for IDA with CKD (Feraheme or Injectafer): Coverage previously provided by UnitedHealthcare based on documented history of intolerance/contraindication/severe adverse event to all three preferred IV products OR treatment failure of at least two of the three preferred IV products; Patient does not have ESRD; Submission of recent laboratory results (within the past 4 to 12 weeks) since the last Feraheme or Injectafer administration to demonstrate need for additional the [...]
- Injectafer (ferric carboxymaltose) for treatment of iron deficiency in adult patients with heart failure and New York Heart Association class II/III to improve exercise capacity when all of the following criteria are met: Submission of medical records supporting the diagnosis of iron deficiency including one of the following: Serum ferritin <100 ng/mL OR both Serum ferritin 100 to 300 ng/mL and Transferrin saturation (TSAT) <20%; Heart failure NYHA class II or NYHA class III; Patient has a left [...]
- For continuation of Injectafer in heart failure: Coverage previously provided by UnitedHealthcare for Injectafer based on documented history of intolerance/contraindication/severe adverse event to all three preferred IV products OR treatment failure of at least two of the three preferred IV products; Submission of recent laboratory results (within the past 4 to 12 weeks) since the last Injectafer administration to demonstrate need for additional therapy; dosing per FDA labeling for iron deficien [...]
4 Active Policies
AETNA-CPB-0520 — Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI
UHC-POL-iv-iron-replacement-therapy — Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
UMR-POL-UMR-iv-iron-replacement-therapy — Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
SUREST-POL-SUREST-iv-iron-replacement-therapy — Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
Related Codes
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