Erythropoiesis Stimulating Agents (ESAs)

Erythropoiesis stimulating agents are covered for FDA‑approved indications when patients have symptomatic anemia or are transfusion dependent, with specific coverage criteria for ESRD on dialysis (Hb <10 g/dL or Hct <30%), CKD not on dialysis (Hb <10 g/dL or Hct <30% plus renal function thresholds), cancer‑related anemia per Medicare NCDs, MDS with bone marrow confirmation and pretreatment EPO ≤500 mU/mL, anemia of chronic disease with iron studies and pretreatment EPO ≤100 mU/mL, and selected preoperative uses for hip/knee or other high‑risk surgeries under specified regimens. Documentation of diagnostic testing (bone marrow biopsy, Hb/Hct, EPO level, iron studies), adherence to NKF and CMS guidance, and monitoring for treatment response (with stop rules such as MDS no response at 2 months) is required; DVT prophylaxis is recommended during perioperative ESA use.

"ESAs are covered for FDA‑approved conditions when the patient has symptomatic anemia or is transfusion dependent."