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Extracorporeal Photopheresis

Section: Surgery
Effective Date: July 01, 2018
Revised Date: August 09, 2019
Last Reviewed: July 16, 2019

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but the drug can alternatively be administered directly to the individual before the white blood cells are withdrawn.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 nonsystemic therapies; or
  • Individual’s with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment; or
  • Individual’s 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

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