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    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAmeriHealth Caritas IV Iron Coverage | OpenPayer
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    ModifiedAmeriHealth Caritas VIP CarePolicy MA08.150b

    Intravenous (IV) Iron Preparations

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    This policy governs Medicare Advantage medical-benefit coverage and medical necessity for intravenous iron products used to treat iron deficiency, iron deficiency anemia, heart failure, and selected cancer- or chemotherapy-induced anemia in adult and pediatric individuals. Coverage is subject to Evidence of Coverage terms, applicable Medicare guidance, and the criteria in this policy.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyIntravenous (IV) Iron Preparations
    Policy CodePolicy MA08.150b
    Change TypeModified
    Effective DateSeptember 18, 2026
    Next Review DateN/A
    Key ActionFor adult iron deficiency or iron deficiency anemia, document intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months before requesting intravenous iron.
    SourceLink
    POLICY UPDATE CHANGES

    HCPCS code A9574 for ferumoxytol injection, 1 mg, was added to the policy.

    Criteria for the use of intravenous iron preparations in pediatric individuals were added.

    Diagnosis codes for chronic blood-loss iron deficiency anemia, other iron deficiency anemias, chemotherapy-related anemia, and anemia complicating pregnancy, childbirth, or the puerperium were added.

    HCPCS code A9574 for injection, ferumoxytol, 1 mg was added to the policy.

    Criteria for the use of intravenous iron preparations in pediatric individuals were added.

    Nine ICD-10 diagnosis codes covering additional iron-deficiency, chemotherapy-related, pregnancy-related, childbirth-related, and puerperium-related anemia were added.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≥3 monthsRequired documented oral iron history for several adult indications
    1 year+Minimum pediatric age for ferric carboxymaltose coverage
    1HCPCS code added in the current revision
    9ICD-10 diagnosis codes added in the prior revision
    PediatricAdditional population with newly added IV iron criteria

    Covered Intravenous Iron Uses

    Adult heart failure

    Covered when the adult individual has the stated indication.

    Heart failure: Adult individual has New York Heart Association class II or III heart failure and is treated with ferric carboxymaltose (for example, Injectafer).

    Adult ID or IDA without CKD

    Covered when ALL of the following are met.

    • Iron deficiency laboratory criterion: Ferritin level is less than 30 ng/mL OR transferrin saturation (TSAT) is less than 20%.Ferritin <30 ng/mL OR TSAT <20%

      Not required for pregnant individuals.

    • Kidney function: Normal kidney function is demonstrated by laboratory values such as urine albumin, creatinine, or glomerular filtration rate (GFR).
    • Oral iron history: Documented intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months.≥3 months

    Adult ID or IDA with CKD

    Covered when ALL of the following are met.

    • Iron deficiency laboratory criterion

      • Nondialysis or peritoneal dialysis: Ferritin level is 100 ng/mL or less AND TSAT is less than 20% in an individual receiving no dialysis or peritoneal dialysis.Ferritin ≤100 ng/mL AND TSAT <20%
      • Hemodialysis: Ferritin level is 200 ng/mL or less AND TSAT is less than 20% in an individual receiving hemodialysis.Ferritin ≤200 ng/mL AND TSAT <20%
    • CKD documentation: Chronic kidney disease is demonstrated by abnormal laboratory values such as urine albumin, creatinine, or GFR.

    Pediatric ferric carboxymaltose

    Covered when ALL of the following are met.

    • Oral iron history

      • Intolerance: Individual has intolerance to oral iron.
      • Unsatisfactory response: Individual has an unsatisfactory response to oral iron.
      • Contraindication: Individual has a contraindication to oral iron, such as inflammatory bowel disease, peptic ulcer disease, or a history of bowel surgery.
    • FDA dosing: Dosing and frequency are in accordance with US Food and Drug Administration (FDA) labeling.

    Pediatric iron dextran

    Covered when ALL of the following are met.

    • Oral iron history

      • Intolerance: Individual has intolerance to oral iron.
      • Unsatisfactory response: Individual has an unsatisfactory response to oral iron.
      • Contraindication: Individual has a contraindication to oral iron, such as inflammatory bowel disease, peptic ulcer disease, or a history of bowel surgery.
    • FDA dosing: Dosing and frequency are in accordance with US Food and Drug Administration (FDA) labeling.

    Pediatric iron sucrose

    Covered when BOTH of the following are met.

    • Diagnosis and maintenance therapy: Individual has iron deficiency anemia on erythropoietin therapy for iron maintenance.

    • CKD type

      • Individual has hemodialysis-dependent CKD.
      • Individual has nondialysis-dependent CKD.
      • Individual has peritoneal dialysis-dependent CKD.
    • FDA dosing: Dosing and frequency are in accordance with US Food and Drug Administration (FDA) labeling.

    Pediatric sodium ferric gluconate complex in sucrose

    Covered when ALL of the following are met.

    • Diagnosis and kidney disease

      • Individual has a documented diagnosis of iron deficiency anemia.
      • Individual has hemodialysis-dependent chronic kidney disease.
    • Supplemental epoetin: Individual is receiving supplemental epoetin therapy.
    • FDA dosing: Dosing and frequency are in accordance with US Food and Drug Administration (FDA) labeling.

    Experimental or investigational uses

    Not covered unless the indication qualifies as an accepted off-label use under the Company's policy on off-label coverage for prescription drugs and biologics.

    Experimental or investigational use: The intravenous iron use does not meet a covered indication in this policy and is not supported as an accepted off-label use under the applicable Company policy.

    All other intravenous iron uses are considered experimental/investigational and are not covered unless the indication is supported as an accepted off-label use under the Company medical policy on off-label coverage for prescription drugs and biologics.

    Initial Therapy Requirements

    Adult non-CKD ID/IDA

    For adults without CKD, covered when all listed initial therapy criteria are met.

    Initial adult non-CKD therapy

    • Adult has iron deficiency or iron deficiency anemia without chronic kidney disease.
    • Iron deficiency laboratory criterion: Ferritin is less than 30 ng/mL OR TSAT is less than 20%.Ferritin <30 ng/mL OR TSAT <20%

      Not required for pregnant individuals.

    • Normal kidney function is demonstrated by laboratory values such as urine albumin, creatinine, or GFR.
    • Documented intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months.

    Required Prior Therapy

    StepPopulation and therapyRequirement before IV ironDocumentation of failure or intolerance
    1Adults with iron deficiency or iron deficiency anemia without CKDTry or assess oral iron supplementationDocument intolerance, contraindication, or nonresponse to oral iron for at least 3 months
    1Adults with iron deficiency or iron deficiency anemia with CKDTry or assess oral iron supplementationDocument intolerance, contraindication, or nonresponse to oral iron for at least 3 months
    StepPediatric therapyRequirement before IV ironQualifying history
    1Ferric carboxymaltose or iron dextranTry or assess oral ironDocument intolerance, an unsatisfactory response, or a contraindication to oral iron

    Billing and Diagnosis Codes

    CPT Procedure Code Number(s)CPT
    N/AN/A
    ICD-10 Procedure Code Number(s)ICD-10
    N/AN/A
    ICD-10 Diagnosis Code Number(s)ICD-10
    D50.0Iron deficiency anemia secondary to blood loss (chronic)
    D50.8Other iron deficiency anemias
    D50.9Iron deficiency anemia, unspecified
    D63.0Anemia in neoplastic disease
    D63.1Anemia in chronic kidney disease
    D64.81Anemia due to antineoplastic chemotherapy
    E61.1Iron deficiency
    O99.011Anemia complicating pregnancy, first trimester
    O99.012Anemia complicating pregnancy, second trimester
    O99.013Anemia complicating pregnancy, third trimester
    1–10 of 13
    1/2
    Management of heart failure with ferric carboxymaltose (Injectafer)ICD-10
    I50.89Other heart failure
    I50.9Heart failure, unspecified
    HCPCS Level II Code Number(s)HCPCS
    J1437Injection, ferric derisomaltose, 10 mg
    J1439Injection, ferric carboxymaltose, 1 mg
    J1750Injection, iron dextran, 50 mg
    J1756Injection, iron sucrose, 1 mg
    J2916Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg
    Q0138Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)
    Q0139Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis)
    HCPCS code added in revision historyHCPCS
    A9574Injection, ferumoxytol, 1 mg
    Revenue Code Number(s)Revenue
    N/AN/A
    Added HCPCS CodeHCPCSCovered
    A9574Injection, ferumoxytol, 1 mg
    Added ICD-10 CodesICD-10Covered
    D50.0Iron deficiency anemia secondary to blood loss (chronic)
    D50.8Other iron deficiency anemias
    D64.81Anemia due to antineoplastic chemotherapy
    O99.011Anemia complicating pregnancy, first trimester
    O99.012Anemia complicating pregnancy, second trimester
    O99.013Anemia complicating pregnancy, third trimester
    O99.019Anemia complicating pregancy, unspecified trimester
    O99.02Anemia complicating childbirth
    O99.03Anemia complicating the puerperium
    Adult non-CKD iron deficiency
    PopulationAdults with iron deficiency or iron deficiency anemia without chronic kidney disease
    Iron-study thresholdFerritin <30 ng/mL OR TSAT <20%
    Pregnancy exceptionThe ferritin/TSAT threshold is not required for pregnant individuals
    Adult CKD, nondialysis or peritoneal dialysis
    PopulationAdults with iron deficiency or iron deficiency anemia with CKD who are not receiving dialysis or who are receiving peritoneal dialysis

    Documentation and Claim Requirements

    Documentation Required

    Adult Non-CKD Oral Iron Trial

    For adult individuals with iron deficiency or iron deficiency anemia without chronic kidney disease, document intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months.

    Documentation Required

    Adult CKD Oral Iron Trial

    For adult individuals with iron deficiency or iron deficiency anemia with chronic kidney disease, document intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months.

    Documentation Required

    Pediatric Oral Iron History

    For pediatric IV iron treatment, document the applicable oral iron history before treatment.

    Appropriate Administration Setting

    Billing Rule

    Use the appropriate office setting

    When intravenous iron can be administered in multiple settings, reimbursement may be limited to the most appropriate and cost-effective setting consistent with the member's medical needs and required monitoring.

    • Office administration is subject to the member's medical condition and required monitoring.
    Billing Rule

    Use the appropriate infusion-center setting

    When intravenous iron can be administered in multiple settings, reimbursement may be limited to the most appropriate and cost-effective setting consistent with the member's medical needs and required monitoring.

    • Infusion center administration is subject to the member's medical condition and required monitoring.

    Clinical Background

    Iron deficiency may result from blood loss, inadequate intake, impaired gastrointestinal absorption, chronic kidney disease, inflammatory or gastrointestinal disease, malignancy, surgery, or other causes. Iron deficiency anemia is evaluated using blood tests such as hemoglobin, mean corpuscular volume, serum iron, ferritin, iron saturation, transferrin, and total iron-binding capacity. Oral iron is generally used first; intravenous iron may be considered when oral iron is not tolerated, is contraindicated, or is ineffective.

    Policy Terms

    CKD
    TermCKD means chronic kidney disease
    Supporting laboratory indicatorsCKD is demonstrated by abnormal urine albumin, creatinine, or glomerular filtration rate (GFR) values
    Policy useCKD status determines the applicable adult iron-study thresholds and pediatric treatment pathways
    HDD-CKD
    TermHDD-CKD means hemodialysis-dependent chronic kidney disease
    Dialysis statusThe individual is dependent on hemodialysis
    Policy useHDD-CKD is a specified CKD type in pediatric iron sucrose and sodium ferric gluconate criteria
    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyIntravenous (IV) Iron Preparations
    Policy CodePolicy MA08.150b
    Change TypeModified
    Effective DateSeptember 18, 2026
    Next Review DateN/A
    Key ActionFor adult iron deficiency or iron deficiency anemia, document intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months before requesting intravenous iron.
    SourceLink
    On This Page
    Covered Intravenous Iron UsesInitial Therapy RequirementsRequired Prior TherapyBilling and Diagnosis CodesDocumentation and Claim RequirementsAppropriate Administration SettingClinical BackgroundPolicy Terms
    Oral iron history: Documented intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months.≥3 months
    ≥3 months

    Adult CKD ID/IDA

    For adults with CKD, covered when all listed initial therapy criteria are met.

    Initial adult CKD therapy

    • Adult has iron deficiency or iron deficiency anemia with chronic kidney disease.

    • Dialysis-specific iron deficiency laboratory criterion

      • Nondialysis or peritoneal dialysis: Ferritin is 100 ng/mL or less AND TSAT is less than 20% in an individual receiving no dialysis or peritoneal dialysis.Ferritin ≤100 ng/mL AND TSAT <20%
      • Hemodialysis: Ferritin is 200 ng/mL or less AND TSAT is less than 20% in an individual receiving hemodialysis.Ferritin ≤200 ng/mL AND TSAT <20%
    • CKD is demonstrated by abnormal laboratory values such as urine albumin, creatinine, or GFR.
    • Documented intolerance, contraindication, or nonresponse to oral iron supplementation for at least 3 months.≥3 months
    Iron-study thresholdFerritin ≤100 ng/mL AND TSAT <20%
    Pregnancy exceptionThe ferritin/TSAT threshold is not required for pregnant individuals
    Adult CKD, hemodialysis
    PopulationAdults with iron deficiency or iron deficiency anemia and CKD who are receiving hemodialysis
    Iron-study thresholdFerritin ≤200 ng/mL AND TSAT <20%
    Pregnancy exceptionThe ferritin/TSAT threshold is not required for pregnant individuals
    Cancer or chemotherapy-induced anemia, absolute iron deficiency
    PopulationAdults with cancer- or chemotherapy-induced anemia who meet the applicable adult requirements
    Iron-study thresholdFerritin <30 ng/mL AND TSAT <20%
    Treatment pathwayIV iron may be used for absolute iron deficiency
    Cancer or chemotherapy-induced anemia, possible functional iron deficiency
    PopulationSelected adults with cancer- or chemotherapy-induced anemia who meet the applicable adult requirements
    Iron-study thresholdFerritin >500–800 ng/mL AND TSAT <50%
    Treatment goalIV iron is used with the goal of avoiding allogeneic transfusion
    Cancer or chemotherapy-induced anemia, functional iron deficiency with ESA
    PopulationIndividuals receiving myelosuppressive chemotherapy without curative intent and ESAs
    Iron-study thresholdFerritin 30–500 ng/mL AND TSAT <50%
    Treatment pathwayIV iron is combined with an erythropoiesis-stimulating agent for functional iron deficiency
    Cancer or chemotherapy-induced anemia without hemoglobin response
    PopulationIndividuals with cancer- or chemotherapy-induced anemia and absolute iron deficiency receiving IV iron with an ESA
    Iron-study thresholdFerritin <30 ng/mL AND TSAT <20%
    Response requirementThere must be no increase in hemoglobin after 4 weeks of IV or oral iron supplementation
  1. Document intolerance to oral iron; an unsatisfactory response to oral iron; or a contraindication to oral iron.
  2. Examples of contraindications include inflammatory bowel disease, peptic ulcer disease, and history of bowel surgery.
    3. Documentation Required

    Maintain Medical Necessity Records

    Maintain medical records demonstrating the medical necessity of the care provided. Records may include documentation from professional provider offices, hospitals, nursing homes, home health agencies, therapies, and test reports.

    Documentation Required

    Clinical and Treatment Documentation

    Ensure the clinical and treatment record supports the applicable coverage criteria for the individual and IV iron product.

    • Document the diagnosis of iron deficiency or iron deficiency anemia and the individual's age.
    • Document kidney function or CKD status, including relevant laboratory values such as urine albumin, creatinine, and GFR.
    • Document iron studies, including ferritin and transferrin saturation, when required; pregnancy status may affect certain requirements.
    • Document oral iron intolerance, contraindication, or nonresponse, as applicable.
    • For CKD-related treatment, document dialysis status, including hemodialysis, peritoneal dialysis, or nondialysis CKD.
    • For cancer- or chemotherapy-induced anemia, document chemotherapy status, iron deficiency parameters, and applicable ESA use or treatment response.
    • For pediatric treatment, document the product-specific diagnosis, CKD status, and required epoetin or erythropoietin therapy, when applicable.
    Billing Rule

    Pediatric FDA-Labeled Dosing

    For pediatric IV iron treatment, document that the administered dose and treatment frequency comply with applicable US Food and Drug Administration (FDA) labeling.

    • Ferric carboxymaltose: pediatric individuals 1 year of age and older.
    • Iron dextran: pediatric individuals 4 months of age and older.
    • Iron sucrose: pediatric individuals 2 years of age and older.
    • Sodium ferric gluconate complex in sucrose: pediatric individuals 6 years of age and older.
    Denial Risk

    Unlisted or Unsupported Indications

    All other uses of intravenous iron are considered experimental or investigational and are not covered unless the indication is supported as an accepted off-label use under the Company's medical policy for off-label coverage of prescription drugs and biologics.

    Denial Risk

    Missing Medical Records

    All requested documentation must be available to the Company upon request. The Company may review or audit services regardless of the provider's participation status; failure to produce requested records demonstrating medical necessity may result in denial of the drug.

    Billing Rule

    Benefit or Contract Limitation

    Coverage is subject to the terms and conditions of the applicable Evidence of Coverage and Medicare Advantage benefit provisions. Benefit limitations, exclusions, and contract terms control coverage even when medical necessity criteria are met.

    Billing Rule

    Code Listing Does Not Guarantee Reimbursement

    Inclusion of a code in the policy's coding table does not imply reimbursement. Claims remain subject to eligibility, benefits, limitations, exclusions, precertification or referral requirements, provider contracts, Company policies, and applicable coding updates.

    • Report services, devices, and pharmaceuticals with the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.
    • The coding table lists CPT, ICD-10, and HCPCS codes related to the specific policy; future applicable coding changes, revisions, or updates also apply.
    Billing Rule

    Use the appropriate hospital outpatient setting

    When intravenous iron can be administered in multiple settings, reimbursement may be limited to the most appropriate and cost-effective setting consistent with the member's medical needs and required monitoring.

    • Hospital outpatient administration is subject to the member's medical condition and required monitoring.
    Billing Rule

    Use the appropriate home setting

    When intravenous iron can be administered in multiple settings, reimbursement may be limited to the most appropriate and cost-effective setting consistent with the member's medical needs and required monitoring.

    • Home administration is subject to the member's medical condition and required monitoring.
    NDD-CKD
    TermNDD-CKD means nondialysis-dependent chronic kidney disease
    Dialysis statusThe individual is not receiving dialysis
    Policy useNDD-CKD is included among the specified CKD types for pediatric iron sucrose coverage
    PDD-CKD
    TermPDD-CKD means peritoneal dialysis-dependent chronic kidney disease
    Dialysis statusThe individual is dependent on peritoneal dialysis
    Policy usePDD-CKD is included among the specified CKD types for pediatric iron sucrose coverage
    TSAT
    TermTSAT means transferrin saturation
    Clinical measureTSAT is an iron-status laboratory measure
    Coverage useTSAT is evaluated with ferritin in the policy's iron deficiency and anemia coverage criteria
    ESAs
    TermESAs means erythropoiesis-stimulating agents
    Policy useESAs are used in specified cancer- and chemotherapy-induced anemia scenarios
    Combination pathwayIV iron may be combined with an ESA for functional iron deficiency during myelosuppressive chemotherapy without curative intent or for absolute iron deficiency without a hemoglobin increase after 4 weeks of IV or oral iron