Darbepoetin Alfa Injection (non-ESRD use): Medical Necessity Denials
Denial Reason, Reason/Remark Code(s)
- CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD
- HCPCS code: J0881
Resolution/Resources
- Jurisdiction 1: Refer to the 'Erythropoiesis Stimulating Agents (ESAs) for the Treatment of Anemia Unrelated to Dialysis Therapy' www.PalmettoGBA.com/j1b/LCD and select Medical Policies under Coverage
- LCD Reconsideration Process: To request changes to any existing LCD, fax clinical evidence/documentation
- Ohio and West Virginia: Refer to the 'Erythropoiesis Stimulating Proteins for Patients Not on Dialysis' Local Coverage Determination and Coverage Articles on the Palmetto GBA Web site for covered conditions:
- South Carolina: Refer to the Coverage article 'Long Acting Synthetic Erythropoiesis': www.PalmettoGBA.com/bsc/LCD and select Medical Policies under Coverage
Advance Beneficiary Notice Information
- If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an Advance Beneficiary Notice (ABN) prior to performing these tests
- ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'
- If you utilize ABNs, they must be issued in advance. Maintain a copy in the patient's medical record. Provide the patient with a copy of the signed notice.
- ABNs must be issued using the standard CMS form. For services provided on or after March 1, 2009, you must use the revised CMS ABN if you are providing advance notice to a beneficiary. Acess the revised form and other background information from the CMS Web site.
- If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Modifier Lookup tool for information on HCPCS modifier GA: