CurrentUnitedHealthcarePolicy CSIND0028.06

Erythropoiesis-Stimulating Agents (for Indiana Only)

This Indiana-only medical benefit drug policy governs coverage and medical necessity determination for specified erythropoiesis-stimulating agents (ESAs) for UnitedHealthcare members in Indiana and applies to providers submitting claims or prior authorization requests in that state.

Policy Summary

PayerUnitedHealthcare

PolicyErythropoiesis-Stimulating Agents (for Indiana Only)

Policy CodePolicy CSIND0028.06

Change TypeRoutine reviewno content changes

Effective DateApril 1, 2025

Next Review DateN/A

Key ActionFollow current InterQual criteria when submitting prior authorization requests for the listed ESAs.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

5ESA products named

7HCPCS/Q codes listed

IndianaState of applicability

InterQualExternal criteria

Coverage & Medical Necessity Criteria

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The listing of a procedure or HCPCS/Q code in this policy is for reference only and does not imply that the service is a covered benefit. Benefit coverage and payment are determined by applicable federal and state laws, and by the member’s contractual plan terms; those requirements may mandate coverage or restrict payment regardless of a code’s presence here. Inclusion of a code does not guarantee reimbursement and other policies or guidelines may apply.

This policy was subject to routine review with no content changes noted on the most recent update; coverage determinations continue to follow the current InterQual clinical criteria and applicable benefit plan requirements. Specific medical necessity or not medically necessary findings are determined by the InterQual topics referenced for each ESA and by the member’s plan terms.

Codes and Billing

Applicable HCPCS/Q codesHCPCS

J0881	Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
J0882	Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)
J0885	Injection, epoetin alfa, (for non-ESRD use), 1000 units
J0887	Injection, epoetin beta, 1 microgram, (for ESRD on dialysis)
J0888	Injection, epoetin beta, 1 microgram, (for non-ESRD use)
Q4081	Injection, epoetin alfa, 100 units (for ESRD on dialysis)
Q5105	Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units
Q5106	Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 units

No codes listed

Prior Authorization, Documentation & Provider Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Aligned to InterQual Criteria — Coverage/medical necessity is determined using the current InterQual® guideline. Providers must obtain prior authorization where required and follow InterQual guidance for clinical criteria.

Prior authorization follows current InterQual® clinical criteria
Providers should verify whether prior authorization is required for the member's specific benefit plan

Step Therapy

Step therapy sequences are not specified in this policy. Providers must consult the current InterQual® criteria and the member’s governing benefit documents for any step therapy requirements imposed by the plan.

No internal step therapy specified in this policy — follow InterQual® and plan benefit rules
If the benefit plan imposes step therapy, documentation of prior therapies and clinical rationale may be required for authorization

Documentation Required

Reference Governing Benefit Documents

Reference Governing Benefit Documents — Benefit coverage is determined by the member’s federal, state, or contractual benefit documents. In the event of any conflict between this policy and those documents, the governing benefit documents prevail. Providers should review the member’s plan terms and furnish any required supporting documentation.

Always verify the member’s specific benefit plan, applicable laws, and contractual terms
Provide supporting clinical documentation when requested to demonstrate medical necessity per the plan

Billing Rule

Coding Inclusion Is Not Coverage

Coding Inclusion Is Not Coverage — The lists of HCPCS/CPT/Q codes in this policy are provided for reference only. Listing a code does not imply that the service is a covered benefit or guarantee payment. Coverage and reimbursement require that the service meet the member’s benefit terms and medical necessity criteria.

Codes shown (e.g., J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106) are reference only
Verify coverage with the member’s benefit plan and submit necessary documentation to support medical necessity

Clinical Background

Erythropoiesis-stimulating agents (ESAs) referenced in this policy include epoetin alfa (Epogen/Procrit), darbepoetin alfa (Aranesp), and methoxy polyethylene glycol-epoetin beta (Mircera), as well as biosimilar epoetin alfa products (e.g., Retacrit). These agents are used to treat anemia associated with various clinical conditions; however, this policy defers to the current InterQual clinical coverage criteria for product-specific indications, initiation and continuation requirements, and documentation expectations.

Definitions & Reference Standards

InterQual — role and references

DefinitionInterQual criteria: third-party clinical guideline sets referenced to determine medical necessity for specific ESA indications.

Products referenced by InterQual topicsAranesp (darbepoetin alfa); Epogen or Procrit (epoetin alfa); Retacrit (epoetin alfa-epbx); Mircera (methoxy polyethylene glycol-epoetin beta)

How used in this policyCoverage and medical necessity are determined by the current release of the InterQual guideline topics listed for each ESA.

Where to find product-specific criteriaInterQual topics: Darbepoetin alfa (Aranesp); Epoetin alfa (Epogen, Procrit); Epoetin alfa-epbx (Retacrit); Methoxy polyethylene glycol-epoetin beta (Mircera).

ScopeInterQual guidance applies to initial and continuation therapy determinations for the named ESAs per this policy.

Initial Therapy — Medical Necessity Logic

Initial therapy

Initial coverage decisions are based on the current InterQual initial therapy criteria for the specific ESA.

Initial therapy: Member meets InterQual initial therapy criteria for the requested ESAsee InterQual

Follow product-specific InterQual topic

Ongoing Therapy — Continuation Criteria

Continuation therapy

Continuation or ongoing therapy coverage must meet ongoing InterQual criteria and applicable benefit plan requirements.

Ongoing treatment: Continued coverage requires ongoing adherence to InterQual continuation criteria and plan-specific requirementssee InterQual

Providers should submit documentation as required by the benefit plan

Step	Requirement/Notes
1	No explicit step therapy sequence is specified in this policy. Follow the current InterQual criteria and the member's benefit plan rules if any step edits exist.

Site of Care / Administration

Note

No site-of-care restrictions in policy — verify plan and InterQual guidance

This policy does not impose site-of-care restrictions; however, the site of administration may be subject to the member's benefit plan terms and applicable InterQual guidance, so confirm plan-specific site rules prior to scheduling or billing.

No site-of-care limitations are specified in this policy.
Follow InterQual and the member's benefit plan for any site-based requirements.

Biosimilar Guidance