Wiki B12 injection for Alimta - Aetna denials


Lincoln, NE
Best answers
I am having problem getting reimbursement from commercial plans such as Aetna for the B12 injection that is required for Alimta. Per the prescribing information, patients are to receive B12 injections. Prior to ICD-10, I did not have any problems getting this covered. I have tried using Z51.11,C34.XX and Z79.899 as it is usually given the same day as chemo - denied for investigative. I have tried just the lung cancer dx - denied investigative. I am going to try Z29.8 but was wondering if anybody might have some insight? Thanks in advance and have a great day!!
Aetna Policy

Have you tried sending in the Alimta policy with the claim? It states right in the Alimta policy that the B12 is considered medically necessary with Alimta.
Use Aetna's Clinical Policy Bulleting to appeal J3420

I've worked with Aetna the past three years and found this same denial for J3420/ Vita B12. In the cases where the patient also received Alimta, I would appeal with the following: medical documentation showing the patient received Alimta on the same DOS as Vita B12. In addition to that, I will send a copy of the first couple of pages of two Clinical Policy Bulletins found on Aetna's website. Clinical Policy Bulletin #0536 discusses Vita B-12. The very first section of that CPB states that Aetna considers Vita B-12 medically necessary for "members receiving Pemetrexed (Alimta)." I also attach CPB #0687 which describes Pemetrexed/Alima. On the second page is states the following: "Note: Physician administration of vitamin B-12 injections is considered medically necessary for individuals receiving pemetrexed (see CBP 536 - Vitamin B-12 Therapy)." I underline those sentences. Aetna pays after receiving all of the above.

Zaida Aquino, CPC
Not sure if anyone found out the correct coding for this, but the LCD for Alimta (L33967) states the correct coding for the B12 with the Alimta. The B12 and the admin for it get T50.995A or T50.995D ONLY.
The only way we've been paid is to appeal the denial with a copy of the package insert showing B-12 is needed and a copy of their policy showing it is covered when given with Alimta. We just have a pre-formatted appeal letter we use since the argument is always the same :)