Medical Policy
Effective Date:09/01/2014 Title:Intravenous Iron Products
Revision Date:08/05/2022 Document:BI452:00
CPT Code(s):C9441, J1439, J1750, J1756, J2916, Q0138, Q0139, Q9970
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Intravenous iron products are covered to treat iron deficiency anemia. 

2)    Covered products include Venofer, Feraheme, Ferrlecit, and Iron Dextran.

3)    Injectafer is not covered.
Medical Statement

Some intravenous iron products are covered for the treatment of iron deficiency anemia, including Venofer, Feraheme, Ferrlecit, and Iron Dextran.

 

Injectafer is not covered.

 

Codes Used In This BI:

Covered

J1756 – Injection, Iron Sucrose, 1mg

Q0138 – Injection, Ferumoxytol, 1gm (for non-ESRD use)

Q0139 – Injection, Ferumoxytol, 1mg (for ESRD on dialysis)

J2916  – Injection, Sodium Ferric Fluconate complex in sucrose injection, 12.5mg

J1750 – Injection, Iron Dextran, 50mg

 

Not covered

C9441 -  Injection, Ferric Carboxymaltose, 1mg

Q9970 -  Injection, Ferric Carboxymaltose, 1mg

J1439 – Injection, Ferric Carboxymaltose, 1mg
Limits
Intentially left empty
Reference

1)    Venofer Product Information.  American Regent, Inc. June 2011.

2)    Feraheme Product Information.  AMAG Pharmaceuticals, Inc. 2014.

3)    Ferrlecit Product Information.  Sanofi-Aventis.  2011.

4)    Infed Product Information.  Watson Pharma, Inc. September 2009.

5)    Auerbach M, Ballard H. Clinical Use of Intravenous:  Administration, Efficacy, and Safety. Hematology Am Soc Hematol Educ Program 2010;2010:338-347
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.