Does S9537 require prior authorization?

No, S9537 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for S9537?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`S9537` — Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, g-csf, gm-csf); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

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

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).

For neonatal encephalopathy/EPO neuroprotection trials: documentation of HIE severity (moderate or severe by clinical criteria), gestational age ≥ 36 weeks (HEAL trial criterion), receipt of therapeutic hypothermia, and timing of EPO doses.

For sickle cell disease DHTR supportive care: documentation that DHTR occurred within 21 days post-transfusion and meets criteria (significant drop in hemoglobin within 21 days post-transfusion plus ≥1 of: new red cell alloantibody, hemoglobinuria, accelerated increase in HbS% with fall in HbA post-transfusion, relative reticulocytopenia or reticulocytosis from baseline, significant LDH rise from baseline, and exclusion of alternative causes).

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)

`S9537` — Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, g-csf, gm-csf); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

S9537 — Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, g-csf, gm-csf); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

`S9537` — Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, g-csf, gm-csf); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem