Home Health & Hospice

Know the Criteria for Osteoporosis Medications

Homecare Insider, February 16, 2009

It seems that more and more agencies are receiving referrals for administration of the two osteoporosis injectable medications, Calcimar® and Forteo®.  Pay attention to some important coverage considerations to consider when planning care and building a case for Medicare coverage.
• Medicare limits coverage to female beneficiaries.
• The patient must have previously sustained a bone fracture that a physician certifies was related to post-menopausal osteoporosis.
• The physician must also certify that the patient is unable to self-inject and that there is no able or willing caregiver available to do this.  Many subcutaneous medications are usually considered to be self-administered so documentation must show why the patient cannot self-inject and that the agency determined there are no caregivers available to learn this.
• The patient should have a diagnosis of senile (post-menopausal) osteoporosis (733.01) to support therapy.

There is a question that has not received a definite answer.  Forteo is administered daily, in most cases for a period of two years.  Does the two-year duration meet Medicare’s definition of a finite period?  Given that this is a defined and documented course of treatment — daily for up to two years — there is the expectation of an end date.  

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