Page 79 - Medicare Benefit Policy Manual

This instruction pertains exclusively to the preoperative surgical indication of the drug
Procrit, in which it is administered to specific patients prior to surgery to reduce risk of
transfusion. It does not affect Medicare policies related to other Food and Drug
Administration (FDA) approved uses of Procrit. It is not a national coverage decision.

Procrit as Preventive Service

The A/B MAC (B) may determine that Procrit is covered for individuals who:

1. Are undergoing hip or knee surgery

2. Have an anemia with a hemoglobin between 10 and 13 mg/dL;

3. Are not a candidate for autologous blood transfusion;

4. Are expected to lose more than 2 units of blood; and

5. Have had a workup so that their anemia appears to be that of chronic disease.

The preoperative use of Procrit may be afforded to these individuals when A/B MACs
(B), exercising their discretion, determine that this treatment is reasonable and necessary.
In other cases, Procrit is considered a preventive service and therefore not covered.

50.5.3 - Oral Anti-Cancer Drugs
(Rev. 1, 10-01-03)
A3-3112.4.B.5, HO-230.4.B.5

Effective January 1, 1994, Medicare Part B coverage is extended to include oral anti-
cancer drugs that are prescribed as anti-cancer chemotherapeutic agents providing they
have the same active ingredients and are used for the same indications as anti-cancer
chemotherapeutic agents which would be covered if they were not self-administered and
they were furnished incident to a physician’s service as drugs and biologicals.

For an oral anti-cancer drug to be covered under Part B, it must:

• Be prescribed by a physician or other practitioner licensed under State law to
prescribe such drugs as anti-cancer chemotherapeutic agents;

• Be a drug or biological that has been approved by the Food and Drug
Administration (FDA);

• Have the same active ingredients as a non-self-administrable anti-cancer
chemotherapeutic drug or biological that is covered when furnished incident to a
physician’s service. The oral anti-cancer drug and the non-self-administrable
drug must have the same chemical/generic name as indicated by the FDA’s