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 |
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. |
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36511 | 36512 | 36513 | 36514 | 36515 | 36516 |
In addition to the listed indications for pheresis therapy, it is also eligible for the treatment of chronic demyelinating gammopathy. |
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