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Effective April 2, 2007
A change in our drug policy for EPO will be effective April 2, 2007, that will require the submission and review of a recent hematocrit (Hct) level (within 30 days of the injection) for EPO claims both on an 837P electronic claim form and/or on a 1500 Health Insurance claim form to determine if the claim is eligible for reimbursement. To view the full EPO (Anemia) drug policy, please select the link under Related Links below or select the link to our Medical Policies under Tools & Resources and Policies & Protocols.
The EPO (Anemia) drug policy change was announced in our September 2006 and January 2007 issues of UnitedHealthcare's Network Bulletin newsletter. The March 2007 issue of UnitedHealthcare's Network Bulletin newsletter will also feature key points about the EPO drug policy change and its effective date on April 2, 2007. Please reference these issues for additional details.
Key Points:
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Effective April 2, 2007
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All physician EPO claims require the hematocrit (Hct) level be submitted with the claim.
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Claims for patients with End Stage Renal Disease (ESRD) receiving erythropoietin must have an Hct of 39 or less to be eligible for reimbursement.
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Claims for erythropoietin for all other patients must have an Hct of 36 or less to be eligible for reimbursement.
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The Hct should be within 30 days of the injection.
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This policy change requires review of the Hct level. If you have the hemoglobin level, it is acceptable to multiply the hemoglobin level times 3 to determine and report the Hct level.
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To expedite claims processing, the Hct should be submitted with the initial claim. Claims without this information will be pended and the Hct level will be requested. A corrected claim with the Hct will need to be submitted.
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Claim instructions on how to submit the Hct on the 1500 Health Insurance claim form and/or 837P electronic claim form can be downloaded or viewed from the 'Related Links' sections below.
Use of EPO
Two independent companies have provided UnitedHealthcare data that suggests that approximately 30% of the EPO is administered to patients that have normal Hct levels. Data suggests that physicians are not intentionally giving EPO to patients that have normal Hct levels; it is believed to be an oversight.
Clinical evidence supports the use of EPO to treat anemia of chronic renal failure when the pre-treatment hematocrit is 39 or less.
The use of EPO to treat anemia of cancer or cancer related therapy, anemia of Zidovudine-treated HIV, and in reduction of allogenic blood transfusion in surgery patients is proven with the pre-treatment hematocrit is 36 or less. Recent clinical studies have described complications related to EPO treatment when given to individuals with normal hematocrit levels.
Additional Questions
If you have any questions about this policy change or the submission of claims, please contact us at unitedoncology@uhc.com. Please include your return email address or a name and phone number if you would like us to call you.
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