Page 81 - Medicare Benefit Policy Manual

Oral drugs that are not approved by the FDA for use as anti-emetics and which are used
by treating physicians adjunctively in a manner incidental to cancer chemotherapy are not
covered by this benefit and are not reimbursable within the scope of this benefit.

It is recognized that a limited number of patients will fail on oral anti-emetic drugs.
Intravenous anti-emetics may be covered (subject to the rules of medical necessity) when
furnished to patients who fail on oral anti-emetic therapy.

More than one oral anti emetic drug may be prescribed and may be covered for
concurrent use if needed to fully replace the intravenous drugs that otherwise would be
given. See the Medicare National Coverage Determinations Manual, Publication 100-03,
Chapter 1, Section 110.18, for detailed coverage criteria.

50.5.5 - Hemophilia Clotting Factors
(Rev. 1, 10-01-03)
A3-3112.4.B.2, HO-230.4.B.2

Section 1861(s)(2)(I) of the Act provides Medicare coverage of blood clotting factors for
hemophilia patients competent to use such factors to control bleeding without medical
supervision, and items related to the administration of such factors. Hemophilia, a blood
disorder characterized by prolonged coagulation time, is caused by deficiency of a factor
in plasma necessary for blood to clot. For purposes of Medicare Part B coverage,
hemophilia encompasses the following conditions:

• Factor VIII deficiency (classic hemophilia);

• Factor IX deficiency (also termed plasma thromboplastin component (PTC) or
Christmas factor deficiency); and

• Von Willebrand’s disease.

Claims for blood clotting factors for hemophilia patients with these diagnoses may be
covered if the patient is competent to use such factors without medical supervision.

The amount of clotting factors determined to be necessary to have on hand and thus
covered under this provision is based on the historical utilization pattern or profile
developed by the contractor for each patient. It is expected that the treating source, e.g., a
family physician or comprehensive hemophilia diagnostic and treatment center, have
such information. From this data, the contractor is able to anticipate and make reasonable
projections concerning the quantity of clotting factors the patient will need over a specific
period of time. Unanticipated occurrences involving extraordinary events, such as
automobile accidents or inpatient hospital stays, will change this base line data and
should be appropriately considered. In addition, changes in a patient’s medical needs
over a period of time require adjustments in the profile.