Coverage for vitamin B-12 injections is determined according to individual or group customer benefits. Payment may be made for vitamin B-12 (J3420) injections only if the patient's diagnosis or condition is one of the following:

• Anemias
  Pernicious anemia (281.0) (Addisonian anemia, Biermier's anemia)
  Macrocytic anemias (281.9)
  Fish tapeworm anemia (123.4)
  Megaloblastic anemia (281.3, 281.9)
  Other vitamin B-12 deficiency anemia (281.1)
  
  
• Gastrointestinal disorders
  Malabsorption syndromes such as sprue (579.1) and idiopathic steatorrhea (579.0)
  Regional enteritis and Crohn's disease (555.0-555.9)
  Other malabsorption syndromes (270.7, 579.3, 579.8, 579.9)
  Surgical or mechanical disorders resulting from resection of the small intestine (e.g., intestinal strictures) (536.9, 557.1, 560.9, 564.2, 564.4, 564.9, 751.1-751.3)
  Intestinal anastomosis (569.89, 997.4-997.5)
  Blind loop syndrome (579.2) and gastrectomy
  States associated with decreased production of intrinsic factor
  
  
• Neuropathies
  Posterolateral sclerosis (266.2)
  Neuropathies associated with pernicious anemia (Addisonian anemia Biermier's anemia)
  The acute phase or acute exacerbation of a neuropathy due to malnutrition or alcoholism, alcohol amnestic syndrome (291.1, 337.1, 337.9, 357.4, 357.5)
  Nutritional optic neuropathy (377.33)
  Toxic optic neuropathy (377.34)
  
  
• Dementias secondary to Vitamin B-12 deficiency (294.10-294.11)
  
  
• Methylmalonic aciduria (791.9)
  
  
• Homocystinuria (270.4)
  
  
• Retrobulbar neuritis associated with heavy smoking (377.32), also known as tobacco amblyopia
  
  
• Other severe, protein-calorie malnutrition (262), other protein calorie malnutrition (263.8)
  
  
• Disturbance of branched-chain amino acid metabolism (270.3)
  
  
• As part of a premedication regimen prior to and during treatment with certain drugs/biologicals with potential significant adverse effects, such as provided with Pemetrexed for injection (Alimta® )(995.20*)

*Diagnosis code 995.20 was effective October 1, 2006.

The use of vitamin B-12 injections for conditions other than those listed above will be denied as not medically necessary, and therefore, not covered. Effective January 26, 2009, a participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement should be maintained in the provider's records.

Oral B-12 vitamins are non-prescription drugs and are not covered.

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.