LCD Reference Article Article

Therapeutic Apheresis for Familial Hypercholesterolemia

A54545

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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General Information

Source Article ID
N/A
Article ID
A54545
Original ICD-9 Article ID
Not Applicable
Article Title
Therapeutic Apheresis for Familial Hypercholesterolemia
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
04/12/2018
Revision Ending Date
N/A
Retirement Date
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CMS National Coverage Policy

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Article Text

National Coverage Determination (NCD) for Apheresis Therapeutic Pheresis (110.14) allows Medicare Administrative Contractor coverage discretion in the use of therapeutic apheresis in the treatment of refractory familial hypercholesterolemia.

Note: CMS Medicare Learning Network (MLN) (MM) 4250 does not apply to or restrict this use.

Noridian covers plasma apheresis for the treatment of familial hypercholesterolemia that is resistant to appropriate lifestyle changes combined with maximal use of statin agents with or without the use of ezetimibe in:
1. Functional homozygotes with an LDL cholesterol greater than 500mg/dl;
2. Functional heterozygotes with no known cardiovascular disease but a LDL cholesterol greater than 300mg/dl;
3. Functional heterozygotes with known cardiovascular disease and a LDL cholesterol greater than 200mg/dl;
4. Familial hypercholesterolemia in pregnancy when the physician feels usual therapy is inadequate to assure uteroplacental perfusion.

All such claims are subject to either pre- or post-pay review by Noridian or any of the authorized Medicare auditors. The need for this procedure must be clearly documented in the medical records for each visit including which pharmacologic agents are/have been used and what lifestyle changes have been made and, if a beneficiary was intolerant of statins, the actual findings and symptoms reported. Be sure that the clinical notes are properly signed by the treating provider and dated for the date of service.

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Coding Information

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ICD-10-CM Codes that Support Medical Necessity

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(2 Codes)
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Group 1 Codes
Code Description
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Bill Type Codes

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Revenue Codes

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Other Coding Information

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/12/2018 R4

Updated to indicate this article is not an LCD Reference Article.

04/12/2018 R3

This article effective 4/12/2018, combines JFA A54544 in JFB A54545 so that both JFA and JFB Contract numbers will have the same final Medicare Coverage Database Article number A54545.

10/01/2016 R2 The article is revised to add new and deleted codes effective 10/1/2016. Added E78.00 and E78.01 and deleted E78.0.
10/01/2015 R1 Noridian has updated the article on Apheresis for Hyperlipidemia to reflect the correct CPT® code for the procedure. The correct CPT® code is 36516 when apheresis is utilized for the treatment of refractory hyperlipidemia. All other aspects of the article remain the same.
Noridian will accept the incorrect CPT® code (36514) that was originally listed until October 1, 2015.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
11/16/2023 04/12/2018 - N/A Currently in Effect You are here
04/02/2018 04/12/2018 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • apheresis
  • therapeutic
  • hypercholesterolemia
  • Apheresis Therapeutic Pheresis
  • 110.14