QualChoice considers Red cell apheresis to be:
Covered for acute sickle cell crisis without prior authorization.
other indications require preauthorization.
QualChoice/QCA considers Plasmapheresis (PP) or plasma exchange (PE) medically
necessary for the following indications (ICD codes in parentheses):
Severe (grades 3-5) Guillain Barre` syndrome (G61.0) (consistent
with guidelines from the American Academy of Neurology, it is generally
considered medically necessary to initiate PE within 2 weeks of onset of
neuropathic symptoms for ambulant individuals and within 4 weeks of symptom
onset for non-ambulant individuals).
Chronic relapsing polyneuropathy (G61.81) (chronic inflammatory
demyelinating polyneuropathy (CIDP)) with severe or life threatening symptoms,
in persons who have failed to respond to conventional therapy.
Treatment of Thrombotic Thrombocytopenic Purpura (TTP) (M31.1)
HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome of
pregnancy (O14.10-O14.23), in persons who are not getting better within 5
days after delivery.
Glomerulonephritis associated with Anti-glomerular basement membrane
antibodies and advancing renal failure or pulmonary hemorrhage (N01.0 –
Goodpasture`s syndrome (M31.0).
Hyperglobulinemias (D89.0 – D89.2, D47.2, C88.0), (including (but
not limited to) multiple myelomas (C90.00, C90.02), Cryoglobulinemia
(D89.1), primary (Waldenstrom`s) Macroglobulinemia (C88.0) or other hyper
viscosity syndromes (C88.2, D89.0 - D89.2).
Myasthenia gravis (G70.00-G70.01), in persons with any of
short-term benefit is critical because of a sudden worsening of symptoms
(such as in impending respiratory crisis)
rapid improvement of strength before surgery or irradiation
chronic intermittent treatment because of failure to respond to all
Last resort treatment of life threatening rheumatoid vasculitis
Pruritus from Cholestatic liver disease (plasma perfusion of charcoal
Scleroderma (M34.0-M34.9) and Polymyositis (M33.20-
M33.29), in persons who are unresponsive to conventional therapy;
Last resort treatment of life threatening systemic lupus erythematosus (SLE)
(M32.0-M32.9) when conventional therapy has failed to prevent clinical
Refsum`s disease (G60.1).
Severe hypercholesterolemia (E78.0) in persons refractory to diet
and maximum drug therapy who are homozygous for familial hypercholesterolemia (LDL
apheresis, also known as heparin-induced extracorporeal LDL precipitation [HELP]
or Dextra Sulfate adsorption) with LDL levels > 500 mg/dL, or persons
heterozygous for familial hypercholesterolemia with LDL levels > 300 mg/dl or >
200 mg/dL with documented history of coronary artery disease. (For this policy,
maximum drug therapy is defined as a 6-month trial of diet plus maximum
tolerated combination drug therapy (defined as a trial of drugs from at least 2
separate classes of Hypolipidemic agents such as bile acid sequestrants, HMG-CoA
reductase inhibitors, fibric acid derivatives, or niacin/nicotinic acids).
Documented history of coronary artery disease is defined as a history of
myocardial infarction, coronary artery bypass surgery, percutaneous transluminal
coronary angioplasty, alternative revascularization procedure, or angina with
coronary artery disease documented by stress test. The frequency of LDL
apheresis that is considered medically necessary varies, but typically averages
about once every 2 weeks to obtain an intrapheresis level of low density
lipoprotein cholesterol (LDL-C) of 120 mg/dl or less. It may be considered
medically necessary to treat individuals with homozygous familial
hypercholesterolemia more frequently).
Hemolytic uremic syndrome (D59.3), when due to autoantibody to
factor H or due to complement factor mutatons.
Moderate to severe active rheumatoid arthritis (M05.00-M06.9) in
adults with longstanding disease who have failed or are intolerant of
disease-modifying anti-rheumatic drugs (DMARD’s).
Renal transplantation (Z94.0) from live donor with ABO
incompatibility or positive cross-match, where a suitable non-reactive live or
cadaveric donor is unavailable.
Acute, severe attack of relapsing remitting multiple sclerosis (G35)
when ALL of the following criteria are met:
Clinically definite or laboratory-supported definite MS
history of a progressive form of the disease
neurological deficit of major proportion, manifest by coma, aphasia,
acute severe cognitive dysfunction, hemiplegia, or paraplegia
minimal pre-attach neurological deficit in the affected area
Failure of at least five days of treatment with high-dose
considers therapeutic apheresis for white blood cells (Leukapheresis) medically
necessary for acute debulking only in members with leukemia (C90.10-C90.12,
QualChoice considers therapeutic apheresis for red blood cells medically
necessary for sickle cell disease (D57.00-D57.02, D57.211-D57.219,
D57.411-D57.419, or D57.811-D57.819).
considers therapeutic apheresis for platelets medically necessary for essential
Thrombocythemia (D47.3) when platelet count is greater than 1,000,000.
Codes Used In
Therapeutic apheresis; for white blood cells
red blood cells
extracorporeal Immunoadsorption and plasma reinfusion
extracorporeal adsorption or filtration and plasma reinfusion