Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-75
Topic: Extracorporeal Photopheresis
Effective Date: August 1, 2005
Issued Date: September 10, 2007
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Extracorporeal photopheresis is eligible for payment. A cycle of extracorporeal photopheresis consists of treatment on two consecutive days, once a month. If there is no response to the treatment within six to eight months, the treatment is stopped. Each day of the two-day cycle should be processed and paid under code 36522.

Description

Extracorporeal photopheresis (code 36522) is a treatment primarily for cutaneous T-cell lymphoma (CTCL), a condition that is generally resistant to chemotherapy and radiotherapy. The treatment begins with oral administration of the drug, Methoxsalen. The patient's blood is then passed through a device that permits exposure of the blood, while it is outside the body (extra-corporeal), to ultraviolet A light. The blood is then returned to the patient. Patients generally receive photopheresis treatment on two consecutive days.

Procedure Codes

36522     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 001 of S-75]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

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.