About this policy
Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD
Coverage indications
Treatment of Primary Immune Thrombocytopenia (ITP) Treatment Treatment is not medically necessary in the following scenarios: Children with no bleeding or mild bleeding (skin manifestations only such as bruising and petechiae) regardless of platelet count Adults with platelet count ≥ 30 x10 9 /L in the absence of bleeding Treatment may be indicated with documentation of at least one of the following conditions: Severe ITP (bleeding) Adult with platelets count ≤30 x10 9 /L especially if risk factors for bleeding are present In preparation for procedures or surgery with risk of bleeding Professional or lifestyle risk factors for trauma Risk factors for bleeding include predisposing comorbidities that increase the risk of bleeding such as uncontrolled hypertension, active peptic ulcer disease, anticoagulation, recent surgery, or head trauma. First-Line Therapy First-line pharmacologic treatment in children and adults is corticosteroids in dosing regimens standard to ITP treatment. Intravenous Immune globulin (IVIg) may be used first-line with documentation of at least one of the following conditions: Documented need for rapid response ( Documented contraindication or inability to tolerate corticosteroids Lack of response to corticosteroids Lack of response is defined as platelet count 9 /L or less than 2-fold increase in baseline platelets 1 . Intravenous anti-D may be used first-line in adults with documentation of at least one of the following conditions in patients who are Rh positive and nonsplenectomized: Documented need for rapid response ( Documented contraindication or inability to tolerate corticosteroids Lack of response to corticosteroids Second-Line Treatment Coverage of second-line treatment requires a documented lack of response to at least one first-line therapy. Shared decision making to consider the risk and benefit of the various second-line options should be documented in the medical record. This should include a discussion of surgical and non-surgical options. Splenectomy will be covered when all of the following criteria are met: Documented lack of response of at least one first-line therapy Documented risk for bleeding (at least one of the following) Severe ITP (bleeding symptoms) Adult with platelets count ≤30 x10 9 /L especially if risk factors for bleeding are present In preparation for procedures or surgery with risk of bleeding Professional or lifestyle risk for trauma Persistent or chronic disease (>6 months) OR documented indication for more immediate surgical intervention ( Pre-operative vaccinations per CDC guidelines Patient desires treatment-free remission and willing to accept the risk associated with splenectomy (surgical, infection and thrombosis) Thrombopoietin receptor agonist (TPO-RA) will be covered when all of the following criteria are met: Documented lack of response of at least one first-line therapy Documented risk for bleeding (at least one of the following) Severe ITP (bleeding symptoms) Risk factors for bleeding are present In preparation for procedures or surgery with risk of bleeding Professional or lifestyle risk factors for trauma Persistent or chronic disease (>6 months) Rituximab will be covered when all of the following criteria are met: Documented lack of response of at least one first line therapy Documented risk for bleeding (at least one of the following) Severe ITP (bleeding symptoms) Risk factors for bleeding are present In preparation for procedures or surgery with risk of bleeding Professional or lifestyle risk for trauma Persistent or chronic disease (>6 months)
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.