Blue Cross Blue Shield of Minnesota Medical Policy

 
 

Medical Policy:
II-192-008
Topic:
Plasma Exchange
Section:
Medicine
Effective Date:
November 4, 2024
Issued Date:
November 4, 2024
Last Revision Date:
August 2024
Annual Review:
August 2024
 
 

Therapeutic apheresis, including plasmapheresis/plasma exchange, involves the selective removal of abnormal cells or substances in the blood that may be associated with disease states. Therapeutic apheresis may also be used to administer treatment, such as plasma constituents present in subtherapeutic concentrations. Plasma exchange is a nonspecific therapy because the entire plasma is discarded. It is also a symptomatic therapy, because it does not remove the source of the pathologic factors. Plasma exchange has been used in a wide variety of acute and chronic conditions, as well as in the setting of solid organ transplantation.

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.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

I.   Initial Review

Plasma exchange may be considered MEDICALLY NECESSARY AND APPROPRIATE for the following indications, when performed by or in consultation with a specialist:

  • Autoimmune Diseases
    • Catastrophic antiphospholipid syndrome (CAPS);
    • Cryoglobulinemia, severe mixed.
  • Hematologic Conditions
    • Atypical hemolytic uremic syndrome (aHUS);
    • HELLP syndrome of pregnancy (characterized by hemolysis [H], elevated liver enzymes [EL], and low platelet [LP] counts);
    • Hyperviscosity syndromes associated with monoclonal gammopathies (e.g., multiple myeloma, Waldenström’s macroglobulinemia);
    • Myeloma with acute renal failure (myeloma cast nephropathy);
    • Thrombotic microangiopathy associated with ticlopidine;
    • Thrombotic thrombocytopenic purpura (TTP).
  • Neurologic Conditions
    • Acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome);
    • Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP);
    • Multiple sclerosis, with acute central nervous system inflammatory demyelination;
    • Myasthenia gravis in crisis or as part of preoperative preparation;
    • N-methyl-D-aspartate (NMDA) receptor antibody encephalitis;
    • Neuromyelitis optica spectrum disorders, acute disease (excluding maintenance therapy);
    • Paraproteinemia polyneuropathy; immunoglobulin A and G;
    • Pediatric acute-onset neuropsychiatric syndrome (PANS)/Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) exacerbation;
    • Progressive multifocal leukoencephalopathy (PML) associated with natalizumab.
  • Renal Diseases
    • Antiglomerular basement membrane disease (Goodpasture syndrome);
    • Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (e.g., granulomatosis with polyangiitis [also known as Wegener’s granulomatosis], microscopic polyangiitis) with associated renal failure;
    • Dense deposit disease with factor H deficiency and/or elevated C3 nephritic factor.
  • Transplantation
    • ABO-incompatible hematopoietic stem cell transplantation;
    • ABO-incompatible solid organ transplantation:
      1. heart (infants);
      2. kidney;
    • Focal segmental glomerulosclerosis after renal transplant;
    • Renal transplantation: antibody-mediated rejection or human leukocyte antigen desensitization;
    • Liver transplantation (desensitization, living donor).
  • Genetic Disorders
    • Wilson disease (fulminant). 

II.   Renewal Review
Plasma exchange may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

  • The patient has been previously approved for therapy through the initial review process; AND
  • The renewal request is for the same indication previously approved; AND
  • The patient has shown positive clinical response from previous plasma exchange treatment (e.g., reduced number and/or severity of infections, decreased use/elimination of prophylactic antibiotics, functional improvement).

III.  Experimental/Investigative Uses

Plasma exchange is considered EXPERIMENTAL/INVESTIGATIVE for all other indications, including but not limited to the following conditions, due to the lack of clinical evidence demonstrating an impact on improved health outcomes:

  • ABO-incompatible solid organ transplant: liver;
  • Acute disseminated encephalomyelitis;
  • Alzheimer’s disease;
  • Amyotrophic lateral sclerosis;
  • Antineutrophil cytoplasmic antibody (ANCA)-associated rapidly progressive glomerulonephritis (granulomatosis with polyangiitis, microscopic polyangiitis) without renal failure;
  • Aplastic anemia;
  • Asthma;
  • Autoimmune hemolytic anemia; warm autoimmune hemolytic anemia; cold agglutinin disease;
  • Chronic fatigue syndrome;
  • Coagulation factor inhibitors;
  • Dermatomyositis and polymyositis;
  • Focal segmental glomerulosclerosis (other than after renal transplant);
  • Heart transplant rejection treatment;
  • Hemolytic uremic syndrome, typical (diarrheal-related);
  • Idiopathic thrombocytopenic purpura (ITP), refractory or nonrefractory;
  • Inclusion body myositis;
  • Lambert-Eaton myasthenic syndrome;
  • Multiple sclerosis with chronic progressive or relapsing remitting course;
  • Overdose and poisoning (e.g., mushroom poisoning);
  • Paraneoplastic syndromes;
  • Paraproteinemia polyneuropathy IgM;
  • Pemphigus vulgaris;
  • Phytanic acid storage disease (Refsum disease);
  • POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes);
  • Psoriasis;
  • Red blood cell alloimmunization in pregnancy;
  • Rheumatoid arthritis;
  • Sepsis;
  • Scleroderma (systemic sclerosis);
  • Stiff person syndrome;
  • Sydenham chorea;
  • Systemic lupus erythematosus (including systemic lupus erythematosus nephritis);
  • Thyrotoxicosis.
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Denial Statements

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Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Acknowledgements:

CPT® codes copyright American Medical Association® 2023. All rights reserved.

CDT codes copyright American Dental Association® 2023. All rights reserved.