Erythropoiesis Stimulating Agents (ESA)
L34356
ESAs are covered to treat significant anemia to reduce transfusion needs in specified populations including ESRD patients on dialysis, CKD patients with marked renal dysfunction, chemotherapy-induced anemia in non-myeloid malignancies, HIV NRTI-induced anemia, select MDS patients, certain perioperative hip/knee cases (epoetin only), and selected chronic inflammatory or hepatitis C treatment-related anemia. Coverage requires documented Hgb/Hct thresholds (commonly Hgb < 10 g/dL or Hct < 30% to initiate), correction/documentation of reversible causes (iron, B12/folate, infection, etc.), adherence to dosing/monitoring targets (general goal Hgb 10–12 g/dL, avoid Hgb > 12 g/dL), and compliance with CMS coding/modifier rules; multiple CMS-specified exclusions and claim-denial rules (modifiers EA/EC/EB and HCPCS J0881/J0885) apply.
"ESA therapy is covered to treat clinically significant anemia by elevating or maintaining red blood cell levels (as demonstrated by Hgb/Hct) to decrease anemia and reduce the need for transfusions."