Covered without prior authorization (high confidence)
Documentation Required
General laboratory documentation: hematocrit (Hct), hemoglobin (Hgb), serum ferritin, serum iron studies and, where relevant, hepatic iron concentration (LIC) measurements; records of prior/concurrent therapies (e.g., testosterone therapy) and clinical signs/symptoms supporting the need for therapeutic phlebotomy
Hematocrit and hemoglobin values as required by indication (examples in policy: Hct ≥55% for erythrocytosis of undetermined etiology; Hct ≥54% or Hb ≥180 g/L for individuals receiving testosterone therapy)
Serum ferritin levels and iron indices for hemochromatosis: policy cites initiation thresholds 'men with serum ferritin levels of 300 ug/L or more and in women with serum ferritin levels of 200 ug/L or more' (Hemochromatosis Management Working Group) and treatment targets ('remove until ferritin 10 to 20 ug/L; maintenance ferritin ≤50 ug/L'); AASLD recommends target ferritin 50–100 µg/L and initiation of phlebotomy in non-HFE iron overload with elevated hepatic iron concentration
Key Coverage Criteria
E29.1 (Testicular hypofunction)
E80.1 (Porphyria cutanea tarda)
D75.1 (Secondary polycythemia)
Erythrocytosis of undetermined etiology where the hematocrit is 55 % or higher
Evidence of elevated hepatic iron concentration for non-hereditary hemochromatosis (policy: 'treatment by phlebotomy of patients with non-HFE iron overload who have an elevated hepatic iron concentration')
Diagnosis documentation for covered conditions (e.g., polycythemia vera, porphyria cutanea tarda, sickle cell crisis, secondary polycythemia due to A-V fistulae/cor pulmonale/cyanotic congenital heart disease)
For polycythemia vera management: documentation of hematocrit control goals and risk stratification per referenced guidelines (policy cites target Hct <45% in PV and use of serial phlebotomy to keep Hct within normal range for low-risk PV)