Pheresis Therapy

Policy ID: S-11-040

Section: Surgery

Effective Date: July 01, 2018

Revised Date: September 25, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Pheresis is a procedure utilizing specialized equipment to remove selected blood constituents (platelets, red blood cells, white blood cells or plasma ) from whole blood and return the remaining constituents to the individual from whom the blood was taken. Different methods of apheresis therapy include pheresis, plasmapheresis, and plasma exchange (PE)

Criteria

Pheresis therapy may be considered medically necessary when performed for ANY of the following indications:

Plasma exchange for:

Autoimmune conditions:
- Catastrophic antiphospholipid syndrome (CAPS); or
  - Severe multiple manifestations of mixed cryoglobulinemia (MC) such as cryoglobulinemic nephropathy, skin ulcers, sensory motor neuropathy, and widespread vasculitis in combination with immunosuppressive treatment; or
  - Systemic lupus erythematosus (SLE), life threatening, as a treatment of last resort; or
Hematologic conditions:
- ABO incompatible hematopoietic stem cell transplantation; or
- Atypical hemolytic-uremic syndrome; or
- Coagulation factor inhibitors or
- HELLP syndrome of pregnancy (a severe form of preeclampsia, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) counts); or
- Hyperviscosity syndromes associated with multiple myeloma, Waldenstrom’s hypergammaglobulinemia, or
- Idiopathic thrombocytopenic purpura in emergency situations; or
- Myeloma with acute renal failure; or
- Plasmapheresis in the treatment of pure red cell aplasia unresponsive to steroid and immunosuppressive therapy, or
- Post-transfusion purpura; or
- Thrombotic thrombocytopenic purpura (TTP); or
Neurological conditions:
- Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); or
- Guillain-Barré syndrome; or
- Multiple sclerosis (MS); acute fulminant central nervous system (CNS) demyelination; or
- Myasthenia gravis in crisis or as part of preoperative preparation; or
- Neuromyelitis optica (NMO); or
- N-methyl-D-aspartate receptor antibody encephalitis; or
- Paraproteinemia polyneuropathy; IgA, IgG (aka Lamber-Eaton syndrome); or
- Post-infectious pediatric neurological conditions (PANDAS and Sydenham’s Chorea); or
Renal conditions:
- ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis [e.g., Wegener’s granulomatosis, also known as granulomatosis with polyangitis (GPA)] with associated renal failure; or
- Anti-glomerular basement membrane disease (Goodpasture’s syndrome); or
- Dense deposit disease with factor H deficiency and/or elevated C3 Nephritic factor; or
- IgA nephropathy (Berger’s Disease); or
Transplant-related conditions:
- Focal segmental glomerulosclerosis after renal transplant; or
- Prior to solid organ transplant, treatment of individuals at high risk of antibody-mediated rejection, including highly sensitized individuals, and those receiving an ABO incompatible organ: or
- Heart (infants); or
- Kidney; or
Renal transplantation;
- antibody mediated rejection; or
- HLA [human leukocyte antigen] desensitization; or
Apheresis therapy for:
- Treatment of chronic relapsing polyneuropathy for individuals with severe or life-threatening symptoms who have failed to respond to conventional therapy; or
- Treatment of life-threatening scleroderma and polymyositis, when the individual is unresponsive to conventional therapy; or
Erythrocytapheresis for:
- Hereditary Hemochromatosis; or
- Polycythemia Vera; or
Leukocytapheresis for:
- Hyperleukocytosis (symptomatic) such as in chronic myelogenous leukemia (CML); or
Red Blood Cell (RBC) exchange transfusion for:
- Acute sickle cell disease; or
- Non-acute sickle cell disease, stroke prophylaxis, pre-operative, in pregnancy or to reduce pain crises; or
Pheresis therapy for:
- Advanced prostate cancer only when used in the development of sipuleucel-T (Provenge); or
- Atopic dermatitis, recalcitrant; or
- Cutaneous T-cell lymphoma/mycosis fungoides/Sezary syndrome, Erythrodermic type; or
- Idiopathic dilated cardiomyopathy; or
- Pruritis due to hepatobiliary diseases (treatment resistant); or
- Systemic amyloidosis due to Beta-2 microglobulin; or
- Toxic epidermal necrolysis (TEN), Refractory; or
- Voltage-gated potassium channel antibody disease; or
- Wilson’s disease, fulminant Plasmapheresis therapy for the following conditions:
  - Plasmapheresis or plasma exchange in the last resort treatment of life-threatening rheumatoid vasculitis when all other conventional therapies have failed; or
  - Plasmapheresis in the treatment of pure red cell aplasia unresponsive to steroid and immunosuppressive therapy.

Contraindications/Exclusions: The following are NOT indications for plasma exchange and will be denied as not medically necessary:

Amyotrophic lateral sclerosis; or
Dermatomyositis/polymyositis; or
Inclusion Body myositis; or
POEMS syndrome; or
Rheumatoid arthritis; or
Schizophrenia.

Pheresis therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

36511

36512

36513

36514

36516

Low-Density Lipid (LDL)

Low-Density Lipid (LDL) apheresis may be considered medically necessary for ALL of the following indications:

Individuals with homozygous familial hypercholesterolemia as an alternative to plasmapheresis; or
Individuals with heterozygous familial hypercholesterolemia who have failed a six (6) month trial of diet therapy, and maximum tolerated combination drug therapy (*), and who meet one of the following FDA-approved indications:
- Functional hypercholesterolemic heterozygotes with LDL cholesterol greater than 100 mg/dl without coronary artery disease; or
- Functional hypercholesterolemic heterozygotes with LDL cholesterol greater than 100 mg/dl and documented coronary artery disease.

* Maximum tolerated drug therapy is defined as a trial of drugs from at least two (2) separate classes of hypolipidemic agents such as PSCK9 inhibitors bile acid sequestrants, HMG-CoA reductase inhibitors, fibric acid derivatives, or Niacin/Nicotinic acids.

Low-Density Lipid (LDL) not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

36516

S2120

Extracorporeal Photopheresis (ECP)

ECP may be considered medically necessary for ANY the following indications:

For treatment of early stage (I or II) cutaneous T-cell lymphoma that is progressive and refractory to established non-systemic therapies; or
For treatment of late-stage (III or IV) cutaneous T-cell lymphoma; 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; or
Prior to lung transplantation for the condition bronchiolitis obliterans syndrome.

ECP not meeting the criteria as indicated in this policy 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

Covered Diagnosis Codes for Procedure Codes: 36522

C84.00

C84.10

D57.04

D57.1

D57.214

D57.414

D57.434

D89.812

D89.813

T86.290

T86.298

Z94.1

Covered Diagnosis Codes for Procedure Codes: 36512, 36513, 36514

C88.0

C90.20

C90.22

C90.30

C90.32

C91.00

C91.01

C91.02

C91.10

C91.11

C91.12

C91.30

C91.31

C91.32

C91.40

C91.42

C91.50

C91.51

C91.52

C91.60

C91.61

C91.62

C91.90

C91.91

C91.92

C91.A0

C91.A1

C91.A2

C91.Z0

C91.Z1

C91.Z2

C92.00

C92.01

C92.02

C92.10

C92.11

C92.12

C92.20

C92.21

C92.22

C92.30

C92.31

C92.32

C92.40

C92.41

C92.42

C92.50

C92.51

C92.52

C92.60

C92.61

C92.62

C92.90

C92.91

C92.92

C92.A0

C92.A1

C92.A2

C92.Z0

C92.Z1

C92.Z2

C93.00

C93.01

C93.02

C93.10

C93.11

C93.12

C93.30

C93.31

C93.32

C93.90

C93.91

C93.92

C93.Z0

C93.Z1

C93.Z2

C94.00

C94.01

C94.02

C94.20

C94.21

C94.22

C94.30

C94.31

C94.32

C94.80

C94.81

C94.82

C95.00

C95.01

C95.02

C95.10

C95.11

C95.12

C95.90

C95.91

C95.92

D45

D58.0

D58.1

D58.2

D58.8

D58.9

D59.30

D59.31

D59.32

D59.39

D60.0

D60.1

D60.8

D60.9

D61.01

D61.09

D61.1

D61.2

D61.3

D61.89

D68.51

D68.52

D68.59

D68.61

D68.62

D69.3

D69.49

D69.59

D75.1

D89.1

D89.2

E78.00

E78.01

E78.41

E78.49

E78.5

E88.09

G35

G36.0

G60.0

G60.1

G60.2

G60.3

G60.8

G60.9

G61.0

G61.81

G61.89

G61.9

G62.2

G62.81

G62.82

G62.89

G62.9

G70.01

K72.10

K72.11

K72.90

K72.91

K76.1

K76.5

K76.89

K77

L29.9

M31.0

M31.30

M31.31

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

M33.20

M33.21

M33.22

M33.29

M34.0

M34.1

M34.2

M34.81

M34.82

M34.83

M34.89

M34.9

N05.0

N05.1

N05.2

N05.3

N05.4

N05.5

N05.6

N05.7

N05.8

N05.9

N06.0

N06.1

N06.3

N06.4

N06.5

N06.6

N06.7

N06.8

N07.0

N07.1

N07.2

N07.3

N07.4

N07.5

N07.6

N07.7

N07.8

N14.0

N14.11

N14.19

N14.2

N14.3

N14.4

N15.0

N15.8

O14.20

T86.11

T86.12

T86.19

T86.290

T86.298

Covered Diagnosis Codes for Procedure Codes: 36511

C61

C88.0

C88.8

C90.00

C90.02

C90.10

C90.11

C90.12

C90.20

C90.22

C90.30

C90.32

C91.00

C91.01

C91.02

C91.10

C91.11

C91.12

C91.30

C91.31

C91.32

C91.40

C91.42

C91.50

C91.51

C91.52

C91.60

C91.61

C91.62

C91.90

C91.91

C91.92

C91.A0

C91.A1

C91.A2

C91.Z0

C91.Z1

C91.Z2

C92.00

C92.01

C92.02

C92.10

C92.11

C92.12

C92.20

C92.21

C92.22

C92.30

C92.31

C92.32

C92.40

C92.41

C92.42

C92.50

C92.51

C92.52

C92.60

C92.61

C92.62

C92.90

C92.91

C92.92

C92.A0

C92.A1

C92.A2

C92.Z0

C92.Z1

C92.Z2

C93.00

C93.01

C93.02

C93.10

C93.11

C93.12

C93.30

C93.31

C93.32

C93.90

C93.91

C93.92

C93.Z0

C93.Z1

C93.Z2

C94.00

C94.01

C94.02

C94.20

C94.21

C94.22

C94.30

C94.31

C94.32

C94.80

C94.81

C94.82

C95.00

C95.01

C95.02

C95.10

C95.11

C95.12

C95.90

C95.91

C95.92

D45

D57.1

D58.0

D58.1

D58.2

D58.8

D58.9

D59.30

D59.31

D59.32

D59.39

D60.0

D60.1

D60.8

D60.9

D61.01

D61.09

D61.1

D61.2

D61.3

D61.89

D68.51

D68.52

D68.59

D68.61

D68.62

D69.3

D69.49

D69.59

D75.1

D89.1

D89.2

E78.00

E78.01

E78.41

E78.49

E78.5

E88.09

G35

G36.0

G60.0

G60.1

G60.2

G60.3

G60.8

G60.9

G61.0

G61.81

G61.89

G61.9

G62.2

G62.81

G62.82

G62.89

G62.9

G70.01

K72.10

K72.11

K72.90

K72.91

K76.1

K76.5

K76.89

K77

L29.9

M31.0

M31.30

M31.31

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

M33.20

M33.21

M33.22

M33.29

M34.0

M34.1

M34.2

M34.81

M34.82

M34.83

M34.89

M34.9

N05.0

N05.1

N05.2

N05.3

N05.4

N05.5

N05.6

N05.7

N05.8

N05.9

N06.0

N06.1

N06.2

N06.3

N06.4

N06.5

N06.6

N06.7

N06.8

N07.0

N07.1

N07.2

N07.3

N07.4

N07.5

N07.6

N07.7

N07.8

N14.0

N14.11

N14.19

N14.2

N14.3

N14.4

N15.0

N15.8

O14.20

T86.11

T86.12

T86.19

T86.290

T86.298

Covered Diagnosis Codes for Procedure Codes: 36516, S2120

D57.1

E78.01

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review,

Updated wording

Internal Medical Policy Committee 1-19-2021 Annual Review

Rearranged criteria within the policy

Internal Medical Policy Committee 5-20-2021 Revision in criteria,

Added several diagnosis codes, update language

Internal Medical Policy Committee 9-21-2021 Coding update Effective October 01, 2021

Removed diagnosis code M31.1

Internal Medical Policy Committee 7-21-2022 Coding update with minor revisions Effective July 04, 2022

Removed Professional Statements and Societal Positions Guidelines
Removed Diagnosis codes: C84.01; C84.02; C84.03; C84.04; C84.05; C84.06; C84.07; C84.08; C84.09; C84.11; C84.12; C84.13; C84.14; C84.15; C84.16; C84.17; C84.18; C84.19; D89.810; D89.811; E78.1; E78.2; E78.3; E83.110; I20.0; I20.1; I20.8; I20.9; I25.110; I25.111; I25.118; I25.119; I25.2; I25.700; I25.701; I25.708; I25.709; I25.710; I25.711; I25.718; I25.719; I25.720; I25.721; I25.728; I25.729; I25.730; I25.731; I25.738; I25.739; I25.750; I25.751; I25.758; I25.759; I25.760; I25.761; I25.768; I25.769; I25.790; I25.791; I25.798; I25.799; I25.9; J42; O14.22; O14.23; T86.00; T86.01; T86.02; T86.03; T86.09; T86.10; T86.13; T86.20; T86.21; T86.22; T86.23; T86.30; T86.31; T86.32; T86.33; T86.39; T86.90; T86.91; T86.99; Z48.21; Z94.81; Z95.1; Z95.5; and Z98.61
Added Diagnosis codes: O14.20

Internal Medical Policy Committee 9-28-2022 Coding update - Effective October 01, 2022

Removed Diagnosis codes D59.3 and N14.1 and
Added Diagnosis codes D59.30; D59.31; D59.32; D59.39; N14.11 and N14.19.

Internal Medical Policy Committee 11-15-2023 Coding update - Effective October 01, 2023

Added Diagnosis codes D57.04, D57.214, D57.414, D57.434, D57.454, and D57.814
Removed Diagnosis code N06.2

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.

Policy ID: S-11-039

Section: Surgery

Effective Date: July 01, 2018

Revised Date: September 20, 2022

Revision Effective Date: October 01, 2022

Last Reviewed: September 28, 2022

Archived Date: October 04, 2023

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Pheresis therapy may be considered medically necessary when performed for ANY of the following indications:

Plasma exchange for:

Autoimmune conditions:
- Catastrophic antiphospholipid syndrome (CAPS); or
  - Severe multiple manifestations of mixed cryoglobulinemia (MC) such as cryoglobulinemic nephropathy, skin ulcers, sensory motor neuropathy, and widespread vasculitis in combination with immunosuppressive treatment; or
  - Systemic lupus erythematosus (SLE), life threatening, as a treatment of last resort; or
Hematologic conditions:
- ABO incompatible hematopoietic stem cell transplantation; or
- Atypical hemolytic-uremic syndrome; or
- Coagulation factor inhibitors or
- HELLP syndrome of pregnancy (a severe form of preeclampsia, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) counts); or
- Hyperviscosity syndromes associated with multiple myeloma, Waldenstrom’s hypergammaglobulinemia, or
- Idiopathic thrombocytopenic purpura in emergency situations; or
- Myeloma with acute renal failure; or
- Plasmapheresis in the treatment of pure red cell aplasia unresponsive to steroid and immunosuppressive therapy, or
- Post-transfusion purpura; or
- Thrombotic thrombocytopenic purpura (TTP); or
Neurological conditions:
- Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); or
- Guillain-Barré syndrome; or
- Multiple sclerosis (MS); acute fulminant central nervous system (CNS) demyelination; or
- Myasthenia gravis in crisis or as part of preoperative preparation; or
- Neuromyelitis optica (NMO); or
- N-methyl-D-aspartate receptor antibody encephalitis; or
- Paraproteinemia polyneuropathy; IgA, IgG (aka Lamber-Eaton syndrome); or
- Post-infectious pediatric neurological conditions (PANDAS and Sydenham’s Chorea); or
Renal conditions:
- ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis [e.g., Wegener’s granulomatosis, also known as granulomatosis with polyangitis (GPA)] with associated renal failure; or
- Anti-glomerular basement membrane disease (Goodpasture’s syndrome); or
- Dense deposit disease with factor H deficiency and/or elevated C3 Nephritic factor; or
- IgA nephropathy (Berger’s Disease); or
Transplant-related conditions:
- Focal segmental glomerulosclerosis after renal transplant; or
- Prior to solid organ transplant, treatment of individuals at high risk of antibody-mediated rejection, including highly sensitized individuals, and those receiving an ABO incompatible organ: or
- Heart (infants); or
- Kidney; or
Renal transplantation;
- antibody mediated rejection; or
- HLA [human leukocyte antigen] desensitization; or
Apheresis therapy for:
- Treatment of chronic relapsing polyneuropathy for individuals with severe or life-threatening symptoms who have failed to respond to conventional therapy; or
- Treatment of life-threatening scleroderma and polymyositis, when the individual is unresponsive to conventional therapy; or
Erythrocytapheresis for:
- Hereditary Hemochromatosis; or
- Polycythemia Vera; or
Leukocytapheresis for:
- Hyperleukocytosis (symptomatic) such as in chronic myelogenous leukemia (CML); or
Red Blood Cell (RBC) exchange transfusion for:
- Acute sickle cell disease; or
- Non-acute sickle cell disease, stroke prophylaxis, pre-operative, in pregnancy or to reduce pain crises; or
Pheresis therapy for:
- Advanced prostate cancer only when used in the development of sipuleucel-T (Provenge); or
- Atopic dermatitis, recalcitrant; or
- Cutaneous T-cell lymphoma/mycosis fungoides/Sezary syndrome, Erythrodermic type; or
- Idiopathic dilated cardiomyopathy; or
- Pruritis due to hepatobiliary diseases (treatment resistant); or
- Systemic amyloidosis due to Beta-2 microglobulin; or
- Toxic epidermal necrolysis (TEN), Refractory; or
- Voltage-gated potassium channel antibody disease; or
- Wilson’s disease, fulminant Plasmapheresis therapy for the following conditions:
  - Plasmapheresis or plasma exchange in the last resort treatment of life-threatening rheumatoid vasculitis when all other conventional therapies have failed; or
  - Plasmapheresis in the treatment of pure red cell aplasia unresponsive to steroid and immunosuppressive therapy.

Contraindications/Exclusions: The following are NOT indications for plasma exchange and will be denied as not medically necessary:

Amyotrophic lateral sclerosis; or
Dermatomyositis/polymyositis; or
Inclusion Body myositis; or
POEMS syndrome; or
Rheumatoid arthritis; or
Schizophrenia.

Pheresis therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

36511

36512

36513

36514

36516

Low-Density Lipid (LDL)

Low-Density Lipid (LDL) apheresis may be considered medically necessary for ALL of the following indications:

Individuals with homozygous familial hypercholesterolemia as an alternative to plasmapheresis; or
Individuals with heterozygous familial hypercholesterolemia who have failed a six (6) month trial of diet therapy, and maximum tolerated combination drug therapy (*), and who meet one of the following FDA-approved indications:
- Functional hypercholesterolemic heterozygotes with LDL cholesterol greater than 100 mg/dl without coronary artery disease; or
- Functional hypercholesterolemic heterozygotes with LDL cholesterol greater than 100 mg/dl and documented coronary artery disease.

Low-Density Lipid (LDL) not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

36516

S2120

Extracorporeal Photopheresis (ECP)

ECP may be considered medically necessary for ANY the following indications:

For treatment of early stage (I or II) cutaneous T-cell lymphoma that is progressive and refractory to established non-systemic therapies; or
For treatment of late-stage (III or IV) cutaneous T-cell lymphoma; 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; or
Prior to lung transplantation for the condition bronchiolitis obliterans syndrome.

ECP not meeting the criteria as indicated in this policy 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

Covered Diagnosis Codes for Procedure Codes: 36522

C84.00

C84.10

D57.1

D89.812

D89.813

T86.290

T86.298

Z94.1

Covered Diagnosis Codes for Procedure Codes: 36512, 36513, 36514

C88.0

C90.20

C90.22

C90.30

C90.32

C91.00

C91.01

C91.02

C91.10

C91.11

C91.12

C91.30

C91.31

C91.32

C91.40

C91.42

C91.50

C91.51

C91.52

C91.60

C91.61

C91.62

C91.90

C91.91

C91.92

C91.A0

C91.A1

C91.A2

C91.Z0

C91.Z1

C91.Z2

C92.00

C92.01

C92.02

C92.10

C92.11

C92.12

C92.20

C92.21

C92.22

C92.30

C92.31

C92.32

C92.40

C92.41

C92.42

C92.50

C92.51

C92.52

C92.60

C92.61

C92.62

C92.90

C92.91

C92.92

C92.A0

C92.A1

C92.A2

C92.Z0

C92.Z1

C92.Z2

C93.00

C93.01

C93.02

C93.10

C93.11

C93.12

C93.30

C93.31

C93.32

C93.90

C93.91

C93.92

C93.Z0

C93.Z1

C93.Z2

C94.00

C94.01

C94.02

C94.20

C94.21

C94.22

C94.30

C94.31

C94.32

C94.80

C94.81

C94.82

C95.00

C95.01

C95.02

C95.10

C95.11

C95.12

C95.90

C95.91

C95.92

D45

D58.0

D58.1

D58.2

D58.8

D58.9

D59.30

D59.31

D59.32

D59.39

D60.0

D60.1

D60.8

D60.9

D61.01

D61.09

D61.1

D61.2

D61.3

D61.89

D68.51

D68.52

D68.59

D68.61

D68.62

D69.3

D69.49

D69.59

D75.1

D89.1

D89.2

E78.00

E78.01

E78.41

E78.49

E78.5

E88.09

G35

G36.0

G60.0

G60.1

G60.2

G60.3

G60.8

G60.9

G61.0

G61.81

G61.89

G61.9

G62.2

G62.81

G62.82

G62.89

G62.9

G70.01

K72.10

K72.11

K72.90

K72.91

K76.1

K76.5

K76.89

K77

L29.9

M31.0

M31.30

M31.31

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

M33.20

M33.21

M33.22

M33.29

M34.0

M34.1

M34.2

M34.81

M34.82

M34.83

M34.89

M34.9

N05.0

N05.1

N05.2

N05.3

N05.4

N05.5

N05.6

N05.7

N05.8

N05.9

N06.0

N06.1

N06.2

N06.3

N06.4

N06.5

N06.6

N06.7

N06.8

N07.0

N07.1

N07.2

N07.3

N07.4

N07.5

N07.6

N07.7

N07.8

N14.0

N14.11

N14.19

N14.2

N14.3

N14.4

N15.0

N15.8

O14.20

T86.11

T86.12

T86.19

T86.290

T86.298

Covered Diagnosis Codes for Procedure Codes: 36511

C61

C88.0

C88.8

C90.00

C90.02

C90.10

C90.11

C90.12

C90.20

C90.22

C90.30

C90.32

C91.00

C91.01

C91.02

C91.10

C91.11

C91.12

C91.30

C91.31

C91.32

C91.40

C91.42

C91.50

C91.51

C91.52

C91.60

C91.61

C91.62

C91.90

C91.91

C91.92

C91.A0

C91.A1

C91.A2

C91.Z0

C91.Z1

C91.Z2

C92.00

C92.01

C92.02

C92.10

C92.11

C92.12

C92.20

C92.21

C92.22

C92.30

C92.31

C92.32

C92.40

C92.41

C92.42

C92.50

C92.51

C92.52

C92.60

C92.61

C92.62

C92.90

C92.91

C92.92

C92.A0

C92.A1

C92.A2

C92.Z0

C92.Z1

C92.Z2

C93.00

C93.01

C93.02

C93.10

C93.11

C93.12

C93.30

C93.31

C93.32

C93.90

C93.91

C93.92

C93.Z0

C93.Z1

C93.Z2

C94.00

C94.01

C94.02

C94.20

C94.21

C94.22

C94.30

C94.31

C94.32

C94.80

C94.81

C94.82

C95.00

C95.01

C95.02

C95.10

C95.11

C95.12

C95.90

C95.91

C95.92

D45

D57.1

D58.0

D58.1

D58.2

D58.8

D58.9

D59.30

D59.31

D59.32

D59.39

D60.0

D60.1

D60.8

D60.9

D61.01

D61.09

D61.1

D61.2

D61.3

D61.89

D68.51

D68.52

D68.59

D68.61

D68.62

D69.3

D69.49

D69.59

D75.1

D89.1

D89.2

E78.00

E78.01

E78.41

E78.49

E78.5

E88.09

G35

G36.0

G60.0

G60.1

G60.2

G60.3

G60.8

G60.9

G61.0

G61.81

G61.89

G61.9

G62.2

G62.81

G62.82

G62.89

G62.9

G70.01

K72.10

K72.11

K72.90

K72.91

K76.1

K76.5

K76.89

K77

L29.9

M31.0

M31.30

M31.31

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

M33.20

M33.21

M33.22

M33.29

M34.0

M34.1

M34.2

M34.81

M34.82

M34.83

M34.89

M34.9

N05.0

N05.1

N05.2

N05.3

N05.4

N05.5

N05.6

N05.7

N05.8

N05.9

N06.0

N06.1

N06.2

N06.3

N06.4

N06.5

N06.6

N06.7

N06.8

N07.0

N07.1

N07.2

N07.3

N07.4

N07.5

N07.6

N07.7

N07.8

N14.0

N14.11

N14.19

N14.2

N14.3

N14.4

N15.0

N15.8

O14.20

T86.11

T86.12

T86.19

T86.290

T86.298

Covered Diagnosis Codes for Procedure Codes: 36516, S2120

D57.1

E78.01

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review,

Updated wording

Internal Medical Policy Committee 1-19-2021 Annual Review

Rearranged criteria within the policy

Internal Medical Policy Committee 5-20-2021 Revision in criteria,

Added several diagnosis codes, update language

Internal Medical Policy Committee 9-21-2021 Coding update Effective October 01, 2021

Removed diagnosis code M31.1

Internal Medical Policy Committee 7-21-2022 Coding update with minor revisions Effective July 04, 2022

Removed Professional Statements and Societal Positions Guidelines
Removed Diagnosis codes: C84.01; C84.02; C84.03; C84.04; C84.05; C84.06; C84.07; C84.08; C84.09; C84.11; C84.12; C84.13; C84.14; C84.15; C84.16; C84.17; C84.18; C84.19; D89.810; D89.811; E78.1; E78.2; E78.3; E83.110; I20.0; I20.1; I20.8; I20.9; I25.110; I25.111; I25.118; I25.119; I25.2; I25.700; I25.701; I25.708; I25.709; I25.710; I25.711; I25.718; I25.719; I25.720; I25.721; I25.728; I25.729; I25.730; I25.731; I25.738; I25.739; I25.750; I25.751; I25.758; I25.759; I25.760; I25.761; I25.768; I25.769; I25.790; I25.791; I25.798; I25.799; I25.9; J42; O14.22; O14.23; T86.00; T86.01; T86.02; T86.03; T86.09; T86.10; T86.13; T86.20; T86.21; T86.22; T86.23; T86.30; T86.31; T86.32; T86.33; T86.39; T86.90; T86.91; T86.99; Z48.21; Z94.81; Z95.1; Z95.5; and Z98.61
Added Diagnosis codes: O14.20

Internal Medical Policy Committee 9-28-2022 Coding update - Effective October 01, 2022

Removed Diagnosis codes D59.3 and N14.1 and
Added Diagnosis codes D59.30; D59.31; D59.32; D59.39; N14.11 and N14.19.

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