Process for Determining Self-Administered Drug Exclusions – Medical Policy Article

CMS directs contractors to determine self-administered drug exclusions on a drug-by-drug basis using evidence (literature, labels, compendia, utilization statistics) and defines 'usually' as self-administered by more than 50% of Medicare beneficiaries. Injectable drugs delivered intravenously or intramuscularly are generally presumed not usually self-administered (and may be payable when furnished 'incident to'), whereas subcutaneous, oral, topical, and suppository routes are generally presumed usually self-administered and excluded; contractors must provide 45 days' notice before denying payment and publish excluded drug lists on contractor and Medicare databases.

"Drugs delivered intravenously are typically not usually self-administered and may be covered when furnished 'incident to' a physician's service."

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