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FDA APPROVED INDICATIONS

Epoetin alfa (Epogen®, Procrit®) is indicated for the treatment of anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis. It is also indicated for the treatment of anemia related to therapy with zidovudine in HIV-infected patients and for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy. Epoetin alfa (Epogen®, Procrit®) is also indicated for the treatment of anemic patients scheduled to undergo elective, noncardiac, nonvascular surgery to reduce the need for allogeneic blood transfusions.

Darbepoetin alfa (Aranesp®) is indicated for the treatment of anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis, and for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy.

Generic Name: Epoetin Alfa, 

Brand Name: Epogen®, Procrit®

Generic Name: Darbepoetin Alfa

Brand Name: Aranesp®

Darbepoetin alfa (Aranesp®) is considered medically necessary for the treatment of anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis, and for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy.

None

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee

1/17/2001: HCPCS code range Q9920-Q9940 added covered codes 

2/2/2001: ICD-9 diagnosis code 285.21 added covered codes

1/30/2002: Prior authorization deleted

2/15/2002: Investigational definition added

4/26/2002: Type of Service and Place of Service deleted. Code Reference section updated. CPT codes 85007, 85027 and 99204 deleted covered codes. ICD-9 diagnosis code 238.7, 272.7, 280.0, 282.60-282.69, 283.2, 285.29, 285.8, 285.8, 773.0, 776.6, 785.6 added non-covered codes, ICD-9 diagnosis codes 285.9, V78.1 and V72.6 deleted covered codes,  ICD-9 procedure code 99.28 deleted covered codes

3/25/2003: Policy section revised, Code Reference section updated, ICD-9 diagnosis code 238.7 moved to covered codes, ICD-9 diagnosis code 203.00, 203.01, 285.22, V58.1 added covered codes, HCPCS range Q9920-Q9940 listed separately covered codes

12/19/2003: Code Reference section reviewed, CPT code 90782, 90784 deleted covered codes, ICD-9 diagnosis code 99.29 deleted covered codes, ICD-9 diagnosis code range 282.60-282.69 listed separately non-covered codes, ICD-9 diagnosis code 282.60, 282.61, 282.62, 282.63, 282.69 description revised non-covered codes, ICD-9 diagnosis code 282.64, 282.68 added non-covered codes

7/9/2004: Code Reference section updated, ICD-9 diagnosis code 585, 586 added covered codes, ICD-9 diagnosis code 593.9 description revised, HCPCS Q9920-9940 deletion date of 12/31/2003 added, HCPCS Q4055 added covered codes

8/11/2005: Code Reference section updated, ICD-9 diagnosis code 283.0 description revised, ICD-9 diagnosis code 285.29 added covered codes, HCPCS Q4054 with effective date of 1/1/2004 added covered codes, HCPCS Q4055 effective date of 1/1/2004 added, HCPCS Q9920, Q9921, Q9922, Q9923, Q9924, Q9925, Q9926, Q9927, Q9928, Q9929, Q9930, Q9931, Q9932, Q9933, Q9934, Q9935, Q9936, Q9937, Q9938, Q9939, Q9940 deleted covered codes, Non-covered codes table and ICD-9 diagnosis code 272.7, 280.0, 282.60, 282.61, 282.62, 282.63, 282.64, 282.68, 282.69, 283.2, 285.29, 285.8, 285.8, 773.0, 776.6, 785.6 deleted

11/8/2005:  Code Reference section updated, 4th digit added to ICD9 diagnosis codes 585.1-585.9, description revised; 5th digit added to code V58.11, description revised

3/6/2006: Aranesp information added to policy. Rewording of policy section to align with indications.

03/23/2006: Coding updated. 2006 revisions added to policy

4/2006: Approved by Pharmacy & Therapeutics (P&T) Committee

9/13/2006: Coding updated. CPT4/HCPCS and ICD9 2006 revisions added to policy.  

9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied

American Hospital Formulary Services, 1998 and 2006

Hayes Directory, July 1996

USPDI, 1998

Procrit® Prescribing Information

Epogen® Prescribing Information

Aranesp® Prescribing Information

Covered Codes

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