ph-0244
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Mircera®

Policy Number: PH-0244

(methoxy polyethylene glycol-epoetin beta) 

Intravenous/Subcutaneous

*NON-DIALYSIS*

 

Last Review Date: 05/02/2022

Date of Origin: 01/06/2015

Dates Reviewed: 01/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 04/2019, 04/2020, 09/2020, 05/2021, 05/2022

Precertification requirements do not apply for this policy. Pre-payment claim edits are applied to diagnosis criteria within this policy.

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization
  • Coverage will be provided for 45 days and may be renewed.
  1. Dosing Limits

A. Quantity Limit (max daily dose) [NDC Unit]:

  • Mircera 30 mcg prefilled syringe: 1 syringe every 14 days
  • Mircera 50 mcg prefilled syringe: 1 syringe every 14 days
  • Mircera 75 mcg prefilled syringe: 1 syringe every 14 days
  • Mircera 100 mcg prefilled syringe: 1 syringe every 14 days
  • Mircera 120 mcg prefilled syringe: 1 syringe every 14 days
  • Mircera 150 mcg prefilled syringe: 1 syringe every 14 days
  • Mircera 200 mcg prefilled syringe: 1 syringe every 28 days
  • Mircera 250 mcg prefilled syringe: 1 syringe every 28 days
  • Mircera 360 mcg prefilled syringe: 1 syringe every 28 days

B. Max Units (per dose and over time) [HCPCS Unit]:

  • 360 billable units every 28 days
  1. Initial Approval Criteria 1-5

     Coverage is provided in the following condition(s):

  • Patient is at least 18 years of age; AND

Universal Criteria

  • Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND
  • Patient has adequate iron stores as demonstrated by serum ferritin ≥ 100 ng/mL (mcg/L) and transferrin saturation (TSAT) ≥ 20% (measured within the previous 3 months for renewal)*; AND
  • Other causes of anemia (e.g. hemolysis, bleeding, vitamin deficiency, etc.) have been ruled out; AND
  • Patient does not have uncontrolled hypertension; AND

Anemia Due to Chronic Kidney Disease (Non-Dialysis Patients) †

  • Initiation of therapy Hemoglobin (Hb) < 10 g/dL and/or Hematocrit (Hct) < 30%

FDA approved indications; Compendia recommended indication(s)

  1. Renewal Criteria 1

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet the universal and other indication-specific relevant criteria identified in section III; AND
  • Previous dose was administered within the past 60 days; AND
  • Disease response with treatment as defined by improvement in anemia compared to pretreatment baseline; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: pure red cell aplasia, severe allergic reactions (anaphylaxis, angioedema, bronchospasm, etc), severe cutaneous reactions (erythema multiforme, Stevens-Johnson Syndrome [SJS]/Toxic Epidermal Necrolysis [TEN], etc.), severe cardiovascular events (stroke, myocardial infarction, congestive heart failure, thromboembolism, etc.), uncontrolled hypertension, seizures, etc.; AND
  • Hemoglobin (Hb) <11 g/dL and/or Hematocrit (Hct) <33%

* Intravenous iron supplementation may be considered when evaluating iron status

  • Functional iron deficiency (i.e., adequate iron stores with an insufficient supply of available iron) may occur in patients with chronic diseases, cancer, and/or in those currently receiving ESAs.
  • Iron is not generally recommended in anemic patients with a Ferritin >500 ng/mL.
  • Anemic patients with a Ferritin ≤500 ng/mL AND TSAT <50% may derive benefit from IV iron therapy in conjunction with ESA.
  1. Dosage/Administration1

Indication

Dose

Anemia due to Chronic Kidney Disease – Non-dialysis

Initial Dose:

Administer 0.6 mcg/kg intravenously or subcutaneously once every 14 days

Maintenance Dose:

Administer once monthly dosing (at twice the every-two-week dose) may occur once Hb has been stabilized. Most commonly the dose ranges from 120 to 360 mcg every 28 days

  • Dose increases of 25% can be considered if after 4 weeks of initial therapy the hemoglobin has increased less than 1 g/dL and the current hemoglobin level is less than the indication specific level noted above.
  • Dose decreases of 25% or more can be considered if the hemoglobin rises rapidly by more than 1 g/dL in any 2-week period.
  • Dose and frequency requested are the minimum necessary for the patient to avoid RBC transfusions.
  • Avoid frequent dose adjustments. Do not increase the dose more frequently than once every 4 weeks; decreases can occur more frequently.
  • If patients fail to respond over a 12-week dose escalation period, further dose increases are unlikely to improve response and discontinuation of therapy should be considered.
  1. Billing Code/Availability Information

HCPCS Code:

  • J0888 – Injection, epoetin beta, 1 microgram, (for non-ESRD use); 1 billable unit = 1 mcg

NDC:

  • Mircera 30 mcg/0.3 mL single-dose prefilled syringe: 59353-0400-xx
  • Mircera 50 mcg/0.3 mL single-dose prefilled syringe: 59353-0401-xx
  • Mircera 75 mcg/0.3 mL single-dose prefilled syringe: 59353-0402-xx
  • Mircera 100 mcg/0.3 mL single-dose prefilled syringe: 59353-0403-xx
  • Mircera 120 mcg/0.3 mL single-dose prefilled syringe: 59353-0407-xx
  • Mircera 150 mcg/0.3 mL single-dose prefilled syringe: 59353-0404-xx
  • Mircera 200 mcg/0.3 mL single-dose prefilled syringe: 59353-0405-xx
  • Mircera 250 mcg/0.3 mL single-dose prefilled syringe: 59353-0406-xx
  • Mircera 360 mcg/0.6 mL single-dose prefilled syringe: 59353-0408-xx
  1. References
  1. Mircera [package insert]. St. Gallen, Switzerland; Vifor (International) Inc. June 2018. Accessed April 2022.
  2. Levin NW, Fishbane S, Cañedo FV, Zeig S, Nassar GM, Moran JE, Villa G, Beyer U, Oguey D; MAXIMA study investigators .: Intravenous methoxy polyethylene glycol-epoetin beta for haemoglobin control in patients with chronic kidney disease who are on dialysis: A randomised non-inferiority trial (MAXIMA). Lancet 370: 1415–1421, 2007.
  3. Sulowicz W, Locatelli F, Ryckelynck JP, Balla J, Csiky B, Harris K, Ehrhard P, Beyer U; PROTOS Study Investigators .: Once-monthly subcutaneous C.E.R.A. maintains stable hemoglobin control in patients with chronic kidney disease on dialysis and converted directly from epoetin one to three times weekly. Clin J Am Soc Nephrol 2: 637–646, 2007.
  4. Fischbach M, Wühl E, Reigner SCM, Morgan Z, Schaefer F. Efficacy and Long-Term Safety of C.E.R.A. Maintenance in Pediatric Hemodialysis Patients with Anemia of CKD [published correction appears in Clin J Am Soc Nephrol. 2019;14(6):907] Clin J Am Soc Nephrol. 2018;13(1):81-90.
  5. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl. 2012;2(suppl):279-335. https://kdigo.org/guidelines/anemia-in-ckd/. Published August 2012.
  6. Mikhail, A., Brown, C., Williams, J.A. et al. Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease. BMC Nephrol 18, 345 (2017).Upd 2020. https://doi.org/10.1186/s12882-017-0688-1.
  7. Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents (ESAs) (L34633). Centers for Medicare & Medicaid Services, Inc. Updated on 06/22/2021 with effective dates 07/01/2021. Accessed April 2022.
  8. First Coast Service Options, Inc. Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents (ESAs) (L36276). Centers for Medicare & Medicaid Services. Updated on 10/22/2021 with effective dates 09/07/2021. Accessed April 2022.
  9. CGS Administrators, LLC. Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents (ESA) (L34356). Centers for Medicare & Medicaid Services. Updated on 02/23/2022 with effective dates 03/03/2022. Accessed April 2022.
  10. First Coast Service Options, Inc. Local Coverage Article (LCA): Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (A57628). Centers for Medicare & Medicaid Services. Updated on 10/08/2021 with effective dates 10/01/2021. Accessed April 2022.
  11. CGS Administrators, LLC. Local Coverage Article (LCA): Billing and Coding: Erythropoiesis Stimulating Agents (ESA) (A56462). Centers for Medicare & Medicaid Services. Updated on 02/23/2022 with effective dates 03/03/2022. Accessed April 2022.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

D63.1

Anemia in chronic kidney disease

I12.9

Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.0

Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.10

Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

N18.30

Chronic kidney disease, stage 3 (moderate), unspecified

N18.31

Chronic kidney disease, stage 3a

N18.32

Chronic kidney disease, stage 3b

N18.4

Chronic kidney disease, stage 4 (severe)

N18.9

Chronic kidney disease, unspecified

Dual coding requirements:

  • Anemia due to CKD (not on dialysis): must bill D63.1 AND I12.9, I13.0, I13.10, N18.3, N18.4, or N18.9

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):

 

Jurisdiction(s): 5, 8

NCD/LCD/LCA Document (s): L34633

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=l34633&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Jurisdiction(s):  N

NCD/LCD/LCA Document (s): L36276

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=l36276&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Jurisdiction(s):  15

NCD/LCD/LCA Document (s): L34356

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=l34356&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Jurisdiction(s):  N

NCD/LCD/LCA Document (s): A57628

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=a57628&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Jurisdiction(s):  15

NCD/LCD/LCA Document (s): A56462

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=a56462&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

MIRCERA (methoxy polyethylene glycol-epoetin beta)

Non-Dialysis Prior Authorization Criteria
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