Cyanocobalamin (Vitamin B-12 injections, J3420) is reimbursed by Medicaid at the point of sale (without prior authorization) for dialysis patients only. However, if the patient has a diagnosis of pernicious anemia a prior authorization request may be submitted for review.
REVIEW CRITERIA: (All of the following must be met)
1. Confirmed diagnosis of Pernicious Anemia
2. Dosing should follow these standard practice guidelines:
Adults: 100 mcg IM/SC once daily for one week. Following clinical improvement, give 100 mcg IM/SC on alternate days for 7 doses, then every 3—4 days for another 2—3 weeks, then 100 mcg IM monthly for life.
Children: 30—50 mcg IM/SC once daily for 2 or more weeks until a total cumulative dose of 1000—5000 mcg IM/SC has been given, then maintenance of 100 mcg IM/SC once every 4 weeks.
Reference: http://www.fdhc.state.fl.us/medicaid/Prescribed_Drug/drug_creteria_pdf/Cyanocablamin.pdf
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