HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-11-033
Topic:
Pheresis Therapy
Section:
Surgery
Effective Date:
December 24, 2018
Issued Date:
December 24, 2018
Last Revision Date:
December 2018
Annual Review:
July 2018
 
 

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. The terms therapeutic apheresis, plasmapheresis, and plasma exchange (PE) are often used interchangeably, but when properly used denote different procedures. 

Policy Position

Pheresis therapy may be considered medically necessary when performed for ANY of the following indications:

  • Plasma exchange for autoimmune conditions:
    • Severe multiple manifestations of mixed cryoglobulinemia (MC) such as cryoglobulinemic nephropathy, skin ulcers, sensory motor neuropathy, and widespread vasculitis in combination with immunosuppressive treatment; or  
    • Catastrophic antiphospholipid syndrome (CAPS).
  • Plasma exchange for hematologic conditions:
    • ABO incompatible hematopoietic progenitor cell transplantation; or
    • Hyperviscosity syndromes associated with multiple myeloma or Waldenstrom’s macroglobulinemia, or
    • Idiopathic thrombocytopenic purpura in emergency situations; or
    • Thrombotic thrombocytopenic purpura (TTP); or
    • Atypical hemolytic-uremic syndrome; or 
    • Post-transfusion purpura; or
    • HELLP syndrome of pregnancy (a severe form of preeclampsia, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) counts); or
    • Myeloma with acute renal failure.
  • Plasma exchange for neurological conditions:
    • Guillain-Barré syndrome; or
    • Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); or 
    • Multiple sclerosis (MS); acute fulminant central nervous system (CNS) demyelination; or
    • Neuromyelitis optica (NMO); or
    • Myasthenia gravis in crisis or as part of preoperative preparation; or
    • Paraproteinemia polyneuropathy; IgA, IgG.
  • Plasma exchange for renal conditions:
    • Anti-glomerular basement membrane disease (Goodpasture’s syndrome); or
    • ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis [e.g., Wegener’s granulomatosis, also known as granulomatosis with polyangitis (GPA)] with associated renal failure; or
    • Dense deposit disease with factor H deficiency and/or elevated C3 Nephritic factor.
  • Plasma exchange for transplantation conditions:
    • Prior to solid organ transplant, treatment of patients at high risk of antibody-mediated rejection, including highly sensitized patients, and those receiving an ABO incompatible organ:
      • Kidney; or
      • Heart (infants); or
    • Renal transplantation: antibody mediated rejection; HLA [human leukocyte antigen] desensitization; or
    • Focal segmental glomerulosclerosis after renal transplant.
  • Apheresis therapy for the following conditions:
    • Apheresis in the treatment of chronic relapsing polyneuropathy for patients with severe or life-threatening symptoms who have failed to respond to conventional therapy; or
    • Apheresis in the treatment of life-threatening scleroderma and polymyositis, when the patient is unresponsive to conventional therapy.
  • Plasmapheresis therapy for the following conditions:
    • Plasmapheresis in the treatment of pure red cell aplasia unresponsive to steroid and immunosuppressive therapy; or
    • *Plasmapheresis or plasma exchange in the last resort treatment of life threatening rheumatoid vasculitis when all other conventional therapies have failed.
  • Pheresis therapy for other conditions:
    • Familial homozygous hypercholesterolemia; or
    • Leukapheresis in the treatment of leukemia; or
    • Systemic lupus erythematosus (SLE), life threatening, as a treatment of last resort; or
    • Chronic myelogenous leukemia; or
    • Advanced prostate cancer only when used in the development of sipuleucel-T (Provenge).


It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage for this indication.

All other indications will be denied as not medically necessary.

36511   

36512   

36513   

36514   

36516




Low-Density Lipid (LDL) apheresis may be considered medically necessary for ALL of the following indications:

  • Patients with homozygous familial hypercholesterolemia as an alternative to plasmapheresis; and
  • Patients with heterozygous familial hypercholesterolemia who have failed a six (6) month trial of diet therapy, and maximum tolerated combination drug therapy(*), and who meet the following FDA-approved indications:
    • Functional hypercholesterolemic heterozygotes with LDL cholesterol greater than 300 mg/dl without coronary artery disease; or
    • Functional hypercholesterolemic heterozygotes with LDL cholesterol greater than 200 mg/dl and documented coronary artery disease.

* Maximum tolerated drug therapy is defined as a trial of drugs from at least two (2) separate classes of hypolipidemic agents such as bile acid sequestrants, HMG-CoA reductase inhibitors, fibric acid derivatives, or Niacin/Nicotinic acids.

Documented coronary artery disease includes a history of myocardial infarction, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty or alternative revascularization procedure, or progressive angina documented by exercise or non-exercise stress test.

All other indications will be denied as not medically necessary.

36516

S2120




Related Policies

Refer to medical policy I-26 Cellular Immunotherapy for Prostate Cancer for additional information.


Covered Diagnosis Codes for Procedure Codes: 36511, 36512, 36513, 36514

 

C61

C88.0

C88.8

C90.00

C90.02

C90.10

C90.11

C90.12

C90.20

C90.22

C90.30

C90.32

C91.00

C91.01

C91.02

C91.10

C91.11

C91.12

C91.30

C91.31

C91.32

C91.40

C91.42

C91.50

C91.51

C91.52

C91.60

C91.61

C91.62

C91.90

C91.91

C91.92

C91.A0

C91.A1

C91.A2

C91.Z0

C91.Z1

C91.Z2 

C92.00

C92.01

C92.02 

C92.10

C92.11 

C92.12 

C92.20 

C92.21 

C92.22 

C92.30 

C92.31

C92.32 

C92.40 

C92.41 

C92.42 

C92.50 

C92.51 

C92.52

C92.60 

C92.61 

C92.62 

C92.90 

C92.91 

C92.92 

C92.A0

C92.A1

C92.A2

C92.Z0 

C92.Z1 

C92.Z2 

C93.00 

C93.01

C93.02 

C93.10 

C93.11 

C93.12 

C93.30 

C93.31 

C93.32

C93.90 

C93.91 

C93.92 

C93.Z0 

C93.Z1 

C93.Z2 

C94.00

C94.01 

C94.02 

C94.20 

C94.21 

C94.22 

C94.30 

C94.31

C94.32 

C94.80 

C94.81 

C94.82 

C95.00 

C95.01 

C95.02

C95.10 

C95.11 

C95.12 

C95.90 

C95.91 

C95.92 

D45

D58.0  

D58.1  

D58.2  

D58.8  

D58.9  

D59.3  

D60.0

D60.1  

D60.8  

D60.9  

D61.01 

D61.09 

D61.1  

D61.2

D61.3  

D61.89 

D68.51 

D68.52 

D68.59 

D68.61 

D68.62

D69.3  

D69.49 

D69.59 

D75.1  

D89.1  

D89.2  

E78.00

E78.01 

E78.1   

E78.2   

E78.3   

E78.5   

E88.09 

G35

G36.0  

G60.0  

G60.1  

G60.2  

G60.3  

G60.8  

G60.9

G61.0  

G61.81 

G61.89 

G61.9  

G62.2  

G62.81 

G62.82

G62.89 

G62.9  

G70.01 

K72.10 

K72.11 

K72.90

K72.91 

K76.1   

K76.5   

K76.89 

K77     

L29.9   

M31.0

M31.1  

M31.30

M31.31

M32.0  

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8  

M32.9  

M33.20

M33.21

M33.22

M33.29

M34.0  

M34.1  

M34.2  

M34.81

M34.82

M34.83

M34.89

M34.9  

M78.41

M78.49

N05.0

N05.1   

N05.2   

N05.3   

N05.4   

N05.5   

N05.6   

N05.7

N05.8   

N05.9   

N06.0   

N06.1   

N06.2   

N06.3   

N06.4

N06.5   

N06.6   

N06.7   

N06.8   

N07.0   

N07.1   

N07.2

N07.3   

N07.4   

N07.5   

N07.6   

N07.7   

N07.8   

N14.0

N14.1   

N14.2   

N14.3   

N14.4   

N15.0   

N15.8   

O14.22

O14.23 

T86.10 

T86.11 

T86.12 

T86.13 

T86.19 

T86.20

T86.21 

T86.22 

T86.23 

T86.290

T86.298

T86.30 

T86.90

T86.91 

T86.92 

T86.93 

T86.99

 

 

 

 

 

 

*C61 is eligible with procedure code 36511 only

For procedure codes 36516, S2120

 

E78.00

E78.01

I20.0

I20.1

I20.8

I20.9

I25.110

I25.111

I25.118

I25.119

I25.2

I25.700

I25.701

I25.708

I25.709

I25.710

I25.711

I25.718

I25.719

I25.720

I25.721

I25.728

I25.729

I25.730

I25.731

I25.738

I25.739

I25.750

I25.751

I25.758

I25.759

I25.760

I25.761

I25.768

I25.769

I25.790

I25.791

I25.798

I25.799

I25.9

Z95.1

Z95.5

Z98.61

 

 

 

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Pheresis therapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



Links






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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.





    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.