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Medicare pays for epoetin or darbepoetin to treat anaemia caused by chemotherapy only when haemoglobin is below 10 g/dL, at the label starting dose, and stops paying if the blood count does not respond within 8 weeks. It does not pay for these drugs to prevent anaemia, for anaemia from radiotherapy alone, or in leukaemias such as AML and CML.
United States, Medicare National Coverage Determination 110.21, version 1, effective 30 July 2007, implemented 7 April 2008. Covered: ESA treatment of "the anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia", only when the haemoglobin immediately before starting or continuing is below 10 g/dL (or haematocrit below 30%); at the FDA label starting dose, "no more than 150 U/kg/3 times weekly for epoetin and 2.25 mcg/kg/1 time weekly for darbepoetin alpha". The dose may be increased once by 25% if haemoglobin rises by less than 1 g/dL over 4 weeks and stays below 10 g/dL; continued use is not covered if the rise is still under 1 g/dL by 8 weeks. A rise of more than 1 g/dL in 2 weeks requires a 25% dose reduction. Each course covers the 8 weeks after the final dose of myelosuppressive chemotherapy.
Not covered: anaemia from folate, B12 or iron deficiency, haemolysis, bleeding or marrow fibrosis; anaemia with treatment of CML, AML or erythroid cancers; anaemia of cancer not related to treatment; anaemia from radiotherapy alone; prophylaxis against chemotherapy-induced anaemia or tumour hypoxia; neutralising-antibody resistance; and patients with uncontrolled hypertension. The NCD's general section notes FDA alerts and warnings and "a higher risk of serious and life-threatening events associated with oncologic uses of ESAs". Local contractors decide on uses the NCD does not address.
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Showing the molecule this term concerns: Epoetin alfa.
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