Archive
API

National Coverage Determination (NCD)

Apheresis (Therapeutic Pheresis)

110.14

Expand All | Collapse All

Tracking Information

Publication Number
100-3
Manual Section Number
110.14
Manual Section Title
Apheresis (Therapeutic Pheresis)
Version Number
1
Effective Date of this Version
07/30/1992
Ending Effective Date of this Version
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service
Outpatient Hospital Services Incident to a Physician's Service
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A. General

Apheresis (also known as pheresis or therapeutic pheresis) is a medical procedure utilizing specialized equipment to remove selected blood constituents (plasma, leukocytes, plataelets, or cells) from whole blood. The remainder is retransfused into the person from whom the blood was taken.

For purposes of Medicare coverage, apheresis is defined as an autologous procedure, i.e., blood is taken from the patient, processed, and returned to the patient as part of a continuous procedure (as distinguished from the procedure in which a patient donates blood preoperatively and is transfused with the donated blood at a later date).
Indications and Limitations of Coverage

B. Indications

Apheresis is covered for the following indications:

  • Plasma exchange for acquired myasthenia gravis;
  • Leukapheresis in the treatment of leukemia;
  • Plasmapheresis in the treatment of primary macroglobulinemia (Waldenstrom);
  • Treatment of hyperglobulinemias, including (but not limited to) multiple myelomas, cryoglobulinemia and hyperviscosity syndromes;
  • Plasmapheresis or plasma exchange as a last resort treatment of thromobotic thrombocytopenic purpura (TTP);
  • Plasmapheresis or plasma exchange in the last resort treatment of life threatening rheumatoid vasculitis;
  • Plasma perfusion of charcoal filters for treatment of pruritis of cholestatic liver disease;
  • Plasma exchange in the treatment of Goodpasture's Syndrome;
  • Plasma exchange in the treatment of glomerulonephritis associated with antiglomerular basement membrane antibodies and advancing renal failure or pulmonary hemorrhage;
  • Treatment of chronic relapsing polyneuropathy for patients with severe or life threatening symptoms who have failed to respond to conventional therapy;
  • Treatment of life threatening scleroderma and polymyositis when the patient is unresponsive to conventional therapy;
  • Treatment of Guillain-Barre Syndrome; and
  • Treatment of last resort for life threatening systemic lupus erythematosus (SLE) when conventional therapy has failed to prevent clinical deterioration.

C. Settings

Apheresis is covered only when performed in a hospital setting (either inpatient or outpatient) or in a nonhospital setting, e.g., a physician directed clinic when the following conditions are met:

  • A physician (or a number of physicians) is present to perform medical services and to respond to medical emergencies at all times during patient care hours;
  • Each patient is under the care of a physician; and
  • All nonphysician services are furnished under the direct, personal supervision of a physician.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
59
Revision History

07/1992 - Provided coverage of apheresis when performed either in an inpatient or outpatient hospital setting or in a nonhospital setting if patient is under the care of a physician and a physician is present to direct and supervise the nonphysician services. Effective date 07/30/1992. (TN 59)

02/1986 - Provided coverage of apheresis for treatment of Guillain-Barre Syndrome and for treatment of life-threatening Systemic Lupus Erythematosus. Effective date 02/14/1986. (TN 4)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Apheresis (Therapeutic Pheresis) 1 07/30/1992 - N/A You are here
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
Submit Feedback/Ask a Question