Mountain State Medical Policy Bulletin

Section: Surgery
Number: S-11
Topic: Pheresis Therapy/ECI
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Pheresis Therapy

Pheresis therapy is considered a "procedure of questionable current usefulness." However, it is eligible for payment when performed for the indications listed below in the Text Attachment.

Claims reporting pheresis therapy for other than the listed indications should be processed in accordance with the guidelines for procedures of questionable current usefulness (see Medical Policy Bulletin G-21).

Once medical necessity has been established, payment may be made under codes 36511, 36512, 36513, and 36514, as appropriate.

Extracorporeal Immunoadsorption

The use of Protein A columns is covered for the treatment of patients with idiopathic thrombocytopenia purpura (ITP)(287.3), or for the treatment of patients with rheumatoid arthritis (RA)(714.0), provided that other treatment methods have been tried and failed. Other uses of these columns are currently considered experimental/investigational in nature as they have not received FDA approval.

Description

Pheresis Therapy

Pheresis is a procedure utilizing specialized equipment to remove selected blood constituents (plasma or cells) from whole blood and return the remaining constituents to the person from whom the blood was taken.

Extracorporeal Immunoadsorption

Extracorporeal immunoadsorption (ECI)(36515, 36516) using Protein A columns (e.g., Prosorba), has been developed for the purpose of selectively removing circulating immune complexes (CIC) and immunoglobulins (IgG) from patients in whom these substances are associated with their diseases. The technique involves pumping the patient's anticoagulated venous blood through a cell separator from which 1 to 3 liters of plasma are collected and perfused over absorbent columns. The plasma rejoins the separated, unprocessed cells and is retransfused to the patient.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

365113651236513365143651536516

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

In addition to the listed indications for pheresis therapy, it is also eligible for the treatment of chronic demyelinating gammopathy.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Table Attachment

Text Attachment

Conditions for Which Pheresis Therapy is Eligible for Payment


  1. Plasma exchange for acquired myasthenia gravis.


  2. Plasmapheresis in the treatment of primary macroglobulinemia (Waldenstrom).


  3. Leukapheresis in the treatment of leukemia.


  4. Apheresis in the treatment of hyperglobulinemias, including (but not limited to) multiple myelomas, cryoglobulinemia and hyperviscosity syndromes.


  5. Plasmapheresis or plasma exchange as a last resort treatment of thrombotic thrombocytopenic purpura (TTP).


  6. Plasmapheresis or plasma exchange in the last resort treatment of life threatening rheumatoid vasculitis when all other conventional therapies have failed.


  7. Plasma exchange in the treatment of Goodpasture's Syndrome.


  8. Plasma exchange in the treatment of glomerulonephritis associated with antiglomerular basement membrane antibodies and advancing renal failure or pulmonary hemorrhage.


  9. Plasmapheresis in the treatment of pure red cell aplasia unresponsive to steroid and immunosuppressive therapy.


  10. Plasma perfusion of charcoal filters for treatment of pruritus of cholestatic liver disease.


  11. Apheresis in the treatment of chronic relapsing polyneuropathy for patients with severe or life-threatening symptoms who have failed to respond to conventional therapy.


  12. Apheresis in the treatment of life-threatening scleroderma and polymyositis, when the patient is unresponsive to conventional therapy.


  13. Guillain-Barré Syndrome


  14. Systemic lupus erythematosus (SLE), life threatening, as a treatment of last resort.


  15. Chronic myelogenous leukemia


  16. Familial homozygous hypercholesterolemia


Procedure Code Attachment


Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.