Coverage for erythropoiesis stimulating agents is determined according to individual or group customer benefits.

DARBEPOETIN ALFA (Aranesp®), EPOETIN ALFA (Epogen®, Procrit®)

Erythropoiesis stimulating agents may be considered reasonable and necessary for the treatment of anemia when reversible causes of anemia are identified and managed. Erythropoiesis stimulating agents may be initiated when the hematocrit (HCT) is less than 36% or the hemoglobin (Hgb) is less than 12g/dL, and when the anemia is associated with any of the following conditions:

1. End stage renal disease (ESRD)(585.6) on dialysis/Chronic Kidney Disease (CKD) Stage V on dialysis

   Erythropoiesis stimulating agents administered on the same day as dialysis are considered an integral part of the dialysis. It is not eligible as a separate and distinct service. If erythropoiesis stimulating agents are reported on the same day as dialysis, and the charges are itemized, combine the charges and pay only the dialysis. Payment for the dialysis performed on the same date of service includes the allowance for the erythropoiesis stimulating agents. A participating, preferred, or network provider cannot bill the member separately for erythropoiesis stimulating agents in this case.

   If the erythropoiesis stimulating agents are given independently, process it under the appropriate code.
   

2. Chronic renal failure not on dialysis/CKD Stage II-V not on dialysis (585.1, 585.2, 585.3, 585.4, 585.5, 585.9)
   
   
3. Renal tubular damage secondary to cisplatin chemotherapy
   
   
4. Treatment of anemia associated with documented multiple myeloma.
   • Patient may or may not be receiving chemotherapy
     
     
5. Antineoplastic Therapy. The following patient indications should apply:
   • Currently receiving a course of antineoplastic therapy or within the last three months
     
     
6. Acquired Immunodeficiency Syndrome (AIDS) or AIDS-Related Complex (ARC) receiving Zidovudine (AZT) therapy. All of the following patient indications should apply:
   • AZT doses of 4200 mg or less/week
   • Endogenous levels of erythropoietin of 500 MU/ml or less
   • Treatment lasting no longer than three months following the discontinuation of the AZT
     
     
7. Myelodysplastic Syndrome
   • Endogenous erythropoietin level should be less than 500 MU/ml
     
     
8. Anemia of prematurity
   
   
9. Anemia associated with chronic illness
   • Anemia of chronic illness is a secondary manifestation of an underlying disorder. Epoetin alfa administration may not be the appropriate treatment choice in anemia of chronic disease, because it typically is not severe.
     
     
10. Preoperative Use. All of the following patient indications must apply:
    • Patient is undergoing noncardiac/nonvascular surgery
    • Patient is not a candidate for autologous blood transfusion
    • Patient is expected to lose more than two units of blood during surgery
    • Preoperative workup has revealed that anemia is related to chronic disease
    • Antithrombotic prophylaxis should be strongly considered for concurrent use

The use of erythropoiesis stimulating agents for any indication not listed on this policy is considered not medically necessary, and therefore, not covered. A participating preferred, or network provider cannot bill the member for the denied service.

NOTE:

Use code J0881 for darbepoetin alfa for non-ESRD use.

Use code J0882 for darbepoetin alfa for ESRD on dialysis.

Use code J0885 for epoetin alfa for non-ESRD use.

Use code J0886 or Q4081 for epoetin alfa for ESRD on dialysis.

NOTE:

See Medical Policy Bulletin G-16 on Chemotherapy for Malignant Disease

Description

Epoetin alfa
Epoetin alfa is a glycoprotein which stimulates red blood cell production. It is produced by the kidney and stimulates the division and differentiation of committed erythroid progenitors in the bone marrow. Epoetin alfa is formulated as a sterile, colorless, preservative-free liquid for intravenous or subcutaneous administration. Epoetin alfa is indicated to elevate or maintain the red blood cell level and to decrease the need for transfusions in selected patients.

Darbepoetin alfa
Darbepoetin alfa is an erythropoiesis stimulating protein, closely related to erythropoietin, that is produced in Chinese hamster ovary cells by recombinant DNA technology. Darbepoetin alfa stimulates erythropoiesis by the same mechanism as endogenous erythropoietin. A primary growth factor for erythroid development, erythropoietin is produced in the kidney and released into the bloodstream in response to hypoxia. In responding to hypoxia, erythropoietin interacts with progenitor stem cells to increase red blood cell production. Darbepoetin alfa is formulated as a sterile, colorless, preservative-free protein solution from intravenous or subcutaneous administration.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition.

USPDI-Vol. 1, Edition 26, 2006 Micromedex, Inc.

Aranesp® (darbepoetin alfa)[package insert]. Thousand Oaks, CA: Amgen, Inc., 2007

Epogen® (epoetin alfa)[package insert]. Thousand Oaks, CA, Amgen, Inc., 2007

Procrit® (epoetin alfa)[package insert]. Thousand Oaks, CA, Amgen, Inc., 2007

NCCN Updates Cancer and Treatment Related Anemia Guidelines. National Comprehensive Cancer Network (NCCN).March 5, 2007

U.S. Food and Drug Administration (FDA). FDA Strengthens Safety Information for Erythropoiesis-Stimulating Agents (ESAs). FDA News. P07-40. Rockville, MD: FDA; March 9, 2007

U.S. Food and Drug Administration (FDA). FDA Public Health Advisory. Epoetin alfa; darbepoetin alfa. Rockville, MD: FDA; November 16, 2006, updated March 9, 2007

Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease, The New England Journal of Medicine, Vol 355, No. 20, 11/2006

Correction of Anemia-Payoffs and Problems, The New England Journal of Medicine, Vol 355, No. 20, 11/2006