EPO: Medicare Reimbursement

• July 1998

  • HCFA plans to develop a national policy on medical justification for physicians who target patients' hematocrits > 36%
  • In the interim, individual patient treatment with EPO will continue to be subject to the physician's discretion
  • Documentation must satisfy the judgment of the fiscal intermediary

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PROGRAM MEMORANDUM. INTERMEDIARIES/CARRIERS. Department of Health and Human Services. Health Care Financing Administration . Transmittal No. AB-98- 34 Date JULY 1998. Change Request #555. SUBJECT:Modification of Medicare Policy for Erythropoietin (EPO) http://www.hcfa.gov/pubforms/transmit/r5ch34p2.htm

HCFA is developing a national policy for Medicare exceptions justifying a target hematocrit greater than 33 to 36 percent. In the interim, upon post-payment review if the treating physician argues it is medically necessary to have a target hematocrit that is greater than 36 percent, then the medical justification must be fully documented and satisfy the judgement of the carrier.