Extracorporeal Photopheresis (ARCHIVED)

Policy ID: S-75-015

Section: Surgery

Effective Date: July 01, 2018

Revised Date: April 06, 2021

Revision Effective Date: July 05, 2021

Last Reviewed: May 20, 2021

Applies To: Commercial and Medicaid Expansion

This policy has been archived effective July 5, 2021. Click the Archive tab above for more information.

Policy ID: S-75-015

Section: Surgery

Effective Date: July 01, 2018

Revised Date: April 06, 2021

Revision Effective Date: July 05, 2021

Last Reviewed: May 20, 2021

Archived Date: July 05, 2021

Applies To: Commercial Only

Description

Extracorporeal photopheresis (ECP) is a medical procedure in which an individual's white blood cells are exposed first to a drug called 8-methoxypsoralen (8-MOP) and then to ultraviolet A (UVA) light. The procedure starts with the removal of the individual's blood to isolate the white blood cells. The drug is typically administered directly to the white blood cells after they have been removed from the individual (referred to as ex vivo administration) but the drug can alternatively be administered directly to the individual before the white blood cells are withdrawn. After UVA light exposure, the treated white blood cells are then re-infused into the individual.

Criteria

ECP may be considered medically necessary for the following indications:

For treatment of late-stage (III or IV) cutaneous T-cell lymphoma; or
For treatment of early stage (I or II) cutaneous T-cell lymphoma that is progressive and refractory to established non-systemic therapies; or
Individuals with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment; or
Individuals with acute or chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment.

ECP for any other indication is considered not medically necessary.

A cycle of ECP consists of treatment on two consecutive days, once per month. If there is no response to the treatment within six to eight months, the treatment should be stopped.

Procedure Codes

36522

Diagnosis Codes

C84.00

C84.01

C84.02

C84.03

C84.04

C84.05

C84.06

C84.07

C84.08

C84.09

C84.10

C84.11

C84.12

C84.13

C84.14

C84.15

C84.16

C84.17

C84.18

C84.19

D89.810

D89.811

D89.812

D89.813

T86.00

T86.01

T86.02

T86.03

T86.09

T86.20

T86.21

T86.22

T86.23

T86.30

T86.31

T86.32

T86.33

T86.39

T86.290

T86.298

Z48.21

Z94.1

Z94.81

Professional Statements and Societal Positions Guidelines

American Society of Blood and Marrow Transplantation-2012

Evidence-based recommendations from the American Society of Blood and Marrow Transplantation (2012) advised that extracorporeal photopheresis (ECP)cannot be considered superior to horse antithymocyte globulin for the treatment of acute GVHD. This conclusion was based on older studies.

National Cancer Institute Acute and Chronic GVHD-2021

In its guidelines on childhood hematopoietic cell transplantation, the National Cancer Institute listed ECP as a second-line treatment for individuals with acute GVHD resistant to first-line methylprednisolone. For chronic GVHD therapy, the guidelines recommended that steroids are first-line therapy, but steroid-sparing approaches, including ECP, are being developed. In this setting, ECP has shown “some efficacy in a percentage of individuals.”

National Comprehensive Cancer Network-2021

National Comprehensive Cancer Network guidelines on primary cutaneous B-cell lymphomas (v.1.2021) lists the use of ECP as a category A treatment alone or in combination with other agents as first-line systemic therapy for advanced (stages III-IV) disease, as well as for individuals with either earlier stage mycosis fungoides with Sézary syndrome involvement.

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Annual Review

Internal Medical Policy Committee 5-20-2021 Archiving Effective July 5, 2021; Criteria and code now included in S-11

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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