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PROGRAM MEMORANDUM. INTERMEDIARIES/CARRIERS. Department of Health and Human Services. Health Care Financing Administration. Transmittal No. AB-98-10 Date MARCH 1998. Change Request #469. SUBJECT: Modification of Medicare Coverage of Erythropoietin (EPO) http://www.hcfa.gov/pubforms/transmit/ab981060.htm
Program Memoranda (PM) AB 97-2, dated February 1997, and AB 97-8, dated May 1997, instructed that no payment be made for EPO during a month if the 90 day average hematocrit exceeded 36.5 percent and described how the three month rolling average hematocrit was to be determined. By this memorandum we are explicitly changing the policy contained in AB 97-2 and AB 97-8 and permitting payment for EPO therapy in a month in which the average hematocrit exceeds 36.5 percent.
Effective for claims for monthly billing periods beginning on or after March 10, 1998, pay claims when the three month rolling average exceeds 36.5 percent. Payment is based on the lower of the actual dosage billed for the current month or 80% of the prior month’s allowable EPO dosage.
This instruction also reestablishes the authorization to make payment for EPO for a month when the patient’s hematocrit exceeds 36 percent. To receive payment, the claim must be accompanied by documentation from the patient’s treating physician or dialysis facility establishing medical necessity for the higher hematocrit. Payment is based on the actual dosage billed.