Quick answer
J1756
What Medicare pays for Venofer (2026 Q4)
2026 Q4 payment limit per billing unit for Venofer’s HCPCS code (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J1756 | Iron sucrose injection | 1 mg | $0.224 |
CMS ASP Drug Pricing File, 2026 Q4. Venofer patient out-of-pocket estimate →
Worked billing example for Venofer
A concrete, paste-checkable example using J1756’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 100 mg adult fixed dose (HDD-CKD, one vial per dialysis session) |
| Dose administered | 100 mg |
| Billing unit basis | 1 unit = 1 mg |
| Billing units (dose ÷ unit basis, rounded up) | 100 units of J1756 |
| Vial combination drawn (min-waste plan) | 1 × 100 mg vial |
| Discarded (waste) | None |
| Wastage modifier (JW / JZ) | Bill all 100 units on a single line with JZ (attests zero drug discarded). JW vs JZ, with examples → |
| Medicare allowable (ASP + 6%, 2026 Q4) | 100 units × $0.224/unit = $22.40 |
Allowable, not paid: sequestration and the covered diagnosis still apply.
Dose source: drugs/venofer.html — HDD-CKD dosing: "100 mg slow IV injection ... 1-3 times per week during dialysis"; FAQ: "used as a whole-vial dose ... with zero waste in adult fixed-dose regimens" (adult regimen, not the pediatric 0.5 mg/kg path). Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Venofer (HCPCS J1756) is paid under Part B only when the claim’s ICD-10 code is one the MAC accepts; otherwise expect a CO-50 denial. How Part B drug coverage is decided →
Covered ICD-10 diagnoses for Venofer
The 7 FDA-approved indications for J1756, grouped by condition — filter to find a code.
Iron Deficiency Anemia — 3 diagnoses (applies to J1756)
Blood, blood-forming organs & immune disorders (3)
| ICD-10 | Covered diagnosis |
|---|---|
| D50.0 | Iron deficiency anemia secondary to blood loss (chronic) |
| D50.8 | Other iron deficiency anemias |
| D50.9 | Iron deficiency anemia, unspecified |
Anemia of CKD — 1 diagnoses (applies to J1756)
Blood, blood-forming organs & immune disorders (1)
| ICD-10 | Covered diagnosis |
|---|---|
| D63.1 | Anemia in chronic kidney disease |
CKD — 3 diagnoses (applies to J1756)
Diseases of the genitourinary system (3)
| ICD-10 | Covered diagnosis |
|---|---|
| N18.4 | Chronic kidney disease, stage 4 |
| N18.5 | Chronic kidney disease, stage 5 |
| N18.6 | End stage renal disease |
What commercial payers require for Venofer
Medicare Part B is only half the answer — most Venofer claims are adjudicated by a commercial plan with its own medical policy. Below is what 9 commercial payers publish for Venofer, read from each payer's own policy document. 4 of 6 that state a position require prior authorization (3 do not say clearly, so confirm those on the call), and 2 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 2 name a preferred product you must try or fail first.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | — | 7 | 2026-07-01 |
| Anthem / Elevance policy ↗ | Required | J1756 | — | 3 | 2025-12-01 |
| Arkansas BCBS policy ↗ | Required | — | — | 4 | — |
| BCBS South Carolina policy ↗ | Required | — | — | 1 | — |
| Excellus BCBS policy ↗ | Not required | — | — | 1 | 2026-07-16 |
| Independence Blue Cross policy ↗ | Not stated — confirm on the call | — | reimbursement limited to the most appropriate, cost-effective setting | 4 | 2026-07-01 |
| Premera Blue Cross policy ↗ | Not stated — confirm on the call | — | Site-of-care program applies | — | 2026-06-01 |
| UnitedHealthcare policy ↗ | Not stated — confirm on the call | — | — | — | 2026-09-01 |
| Wellmark BCBS policy ↗ | Not required | J1756 | — | 1 | 2025-01-01 |
What Venofer payers put in writing
Quoted from the medical policies linked above — 18 distinct requirements across 9 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Individual has had a four (4) week trial of and inadequate response, or intolerance to oral iron supplementation
— Anthem / Elevance policy ↗Serum ferritin levels less than 100 ng/mL
— Anthem / Elevance policy ↗The member must be 18 years of age or older.
— BCBS South Carolina policy ↗Serum ferritin less than 30 ng/mL OR transferrin saturation (TSAT) less than 20%, OR an absence of stainable iron in bone marrow.
— BCBS South Carolina policy ↗Measured ferritin level is less than 100 ng/mL, transferrin saturation (TSAT) less than 30%, or an absence of stainable iron in bone marrow
— BCBS South Carolina policy ↗All lab values submitted must be within 60 days of request.
— BCBS South Carolina policy ↗
Prior authorization
Precertification of Feraheme, Ferrlecit, generic sodium ferric gluconate, Injectafer, Monoferric, Venofer, and generic iron sucrose are required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization)
— Anthem / Elevance policy ↗Based upon our assessment, the Health Plan considers the following medications medically appropriate and covered without prior authorization.
— Excellus BCBS policy ↗The preferred products are considered medically necessary and do not require prior authorization.
— Wellmark BCBS policy ↗
Quantity and frequency limits
Adult Hemodialysis Dependent Chronic Kidney Disease (HDD-CKD): 100 mg slow intravenous injection or infusion.
— Aetna policy ↗Adult Non-Dialysis Dependent Chronic Kidney Disease (NDD-CKD): 200 mg slow intravenous injection or infusion.
— Aetna policy ↗Adult Peritoneal Dialysis Dependent-Chronic Kidney Disease (PDD-CKD): 300 mg or 400 mg intravenous infusion.
— Aetna policy ↗0.5 mg/kg, not to exceed 100 mg per dose, every two weeks for 12 weeks.
— Aetna policy ↗Initial Duration of Approval: 3 months
— BCBS South Carolina policy ↗Venofer should be administered at a dose of 0.5 mg/kg, not to exceed 100 mg per dose, every 2 weeks for 12 weeks
— Excellus BCBS policy ↗
Site-of-care restrictions
The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting
— Independence Blue Cross policy ↗
Exclusions and contraindications
Aetna considers intravenous iron therapy contraindicated and experimental, investigational, or unproven for members with genetic hemochromatosis or hemochromatosis secondary to iron overload.
— Aetna policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Venofer
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J1756. Matching codes, units and JZ/JW wastage →
Which policy governs Venofer
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Venofer is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J1756, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Venofer covered by Medicare?
- Yes. Venofer (J1756) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point. None of the 8 Medicare Administrative Contractors lists J1756 as self-administered.
- What diagnoses are covered for Venofer (J1756)?
- Medicare publishes no drug-specific covered-diagnosis list for J1756. The 7 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Venofer?
- No drug-specific LCD or Billing & Coding Article exists for Venofer. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Venofer claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J1756. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Venofer's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Venofer cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Venofer — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Venofer prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Venofer”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-09-21; we re-verify against CMS quarterly).
- Notes
- ICD-10-CM is public domain; CPT® (AMA) is intentionally not listed. Reference, not billing advice — built from the CMS Coverage API per our methodology; corrections to editorial@carecostestimate.com.