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Benefit Limitations for Epoetin Beta (Mircera)

Last updated on 4/24/2019

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective April 18, 2019, for dates of service on or after April 1, 2019, diagnosis limitations for epoetin beta (Mircera) procedure code J0888 have changed.

Procedure code J0888 is restricted to the following diagnosis codes:

Diagnosis Codes

D631

I120

I129

I130

I1311

I132

N181

N182

N183

N184

N185

N186

Affected claims submitted April 1, 2019, through April 18, 2019, will be reprocessed and may result in an additional payment or recoupment, which will be reflected on future Remittance and Status Reports.

Procedure code J0888 is limited to one injection every two calendar weeks, any provider (Sunday through Saturday).

Mircera may be considered for reimbursement when the dose is titrated consistent with prevailing, evidence-based clinical guidelines, as published by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative, including appropriate monitoring of the rise and fall of the hemoglobin or hematocrit levels.

Treatment Indications

Methoxy polyethylene glycol-epoetin beta (Mircera) is indicated for the treatment of anemia associated with chronic kidney disease (CKD) and may be administered subcutaneously or intravenously. Mircera is not indicated for use in the treatment of anemia due to cancer chemotherapy or as a substitute for red blood cell transfusions in patients who require immediate correction of anemia. Mircera is indicated for the following:

  • Treatment of anemia associated with CKD in adult patients on hemodialysis and adult patients not on hemodialysis.
  • Treatment of anemia associated with CKD in pediatric patients ages 5 to 17. These patients must be on hemodialysis and converting from another erythropoiesis-stimulating agent (ESA) after their hemoglobin level was stabilized with an ESA.

Note: In pediatric patients, Mircera is administered by intravenous injection only.

For more information, call the TMHP Contact Center at 800-925-9126.