About this policy
National Coverage Determination (NCD) for Apheresis Therapeutic Pheresis (110.14) allows Medicare Administrative Contractor coverage discretion in the use of therapeutic apheresis in the treatment of refractory familial hypercholesterolemia. Note: CMS Medicare Learning Network (MLN) (MM) 4250 does not apply to or restrict this use. Noridian covers plasma apheresis for the treatment of familial hypercholesterolemia that is resistant to appropriate lifestyle changes combined with maximal use of statin agents with or without the use of ezetimibe in: 1. Functional homozygotes with an LDL cholesterol greater than 500mg/dl; 2. Functional heterozygotes with no known cardiovascular disease but a LDL cholesterol greater than 300mg/dl; 3. Functional heterozygotes with known cardiovascular disease and a LDL cholesterol greater than 200mg/dl; 4. Familial hypercholesterolemia in pregnancy when the physician feels usual therapy is inadequate to assure uteroplacental perfusion. All such claims are subject to either pre- or post-pay review by Noridian or any of the authorized Medicare auditors. The need for this procedure must be clearly documented in the medical records for each visit including which pharmacologic agents are/have been used and what lifestyle changes have been made and, if a beneficiary was intolerant of statins, the actual findings and symptoms reported. Be sure that the clinical notes are properly signed by the treating provider and dated for the date of service.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.