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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but the drug can alternatively be administered directly to the individual before the white blood cells are withdrawn.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.
ECP may be considered medically necessary for the following indications:
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.
Z94.81
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.
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
References (PDF)
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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