The injection must be reasonable and necessary for diagnosis or treatment of an illness
or injury for program payment to be made. If any of the following conditions prevail,
the injection will not be covered:
Injections which are not considered by accepted standards of medical practice to be
indicated as a specific or effective treatment for the particular condition for which they are given. Vitamin B12 injections,
for example, are specific therapy (and will be covered) for certain anemias, gastro-intestinal
disorders and neuropathies. Vitamin B12 or any other injection not administered for
one of these specific reasons, is excluded from coverage.
Medications which are given for a purpose other than treatment of a particular condition,
illness, or injury. For example, the entire charge for vitamin injections given simply
for the general good and welfare of the patient and not as accepted therapy for a
Injections which are not considered an indicated method of administration according
to accepted standards of medical practice for the condition for which given.
Medications administered for treatment of a disease which exceed the frequency or
duration of injections indicated by accepted standards of medical practice as an appropriate
level of care for that condition, unless there are extenuating circumstances.
For example, scientific studies have shown that an injection of vitamin B12 at a dose
of from 100 to 1,000 micrograms no more frequently than once monthly is the accepted,
necessary, and reasonable dosage schedule for maintenance treatment for an individual with pernicous anemia. More frequent injections would
be appropriate in the initial or acute phase of the disease until it has been determined
through laboratory tests that the patient can be sustained on the maintenance dosage.
Another example: Standard medical practice indicates the use of parental penicillin
or other antibiotics for the initiation of, but not for the entirety of, the course
of treatment for an infectious disease. The entire charge for these penicillin injections
(those exceeding the initial standard dosage) is excluded from coverage unless there
are special medical circumstances which justify the additional injections.