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Medicare Carriers Manual Part 3. Chapter IV - Claims Review and Adjudication Procedures. http://www.hcfa.gov/pubforms/14%5Fcar/3b4271.htm
10-91 CLAIMS REVIEW AND ADJUDICATION PROCEDURES 4273.1 4273. CLAIMS FOR PAYMENT FOR EPOETIN ALFA (EPO)
Effective June 1, 1989, the drug EPO is covered under Part B if administered incident to a physician's services. EPO is used to treat anemia associated with chronic renal failure, including patients on dialysis and those who are not on dialysis.
4273.1 Completion of Initial Claim for EPO.--The following information is required:
Diagnoses, Hematocrit (HCT)/Hemoglobin (Hgb), Units Administered, Date of the patient's most recent HCT or Hg, Most recent HCT or Hgb level prior to initiation of EPO therapy, Date of most recent HCT or Hgb level prior to initiation of EPO therapy, Patient's most recent serum creatinine, within the last month, prior to initiation of EPO therapy, Date of most recent serum creatinine prior to initiation of EPO therapy, Patient's weight in kilograms, Patient's starting dose per kilogram.
