Local Coverage Article

Therapeutic Apheresis for Familial Hypercholesterolemia

A54543

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Contractor Information

Article Information

General Information

Article ID
A54543
Article Title
Therapeutic Apheresis for Familial Hypercholesterolemia
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
04/12/2018
Revision Ending Date
N/A
Retirement Date
N/A
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Article Guidance

Article Text
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.

Coding Information

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
36516 THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL IMMUNOADSORPTION, SELECTIVE ADSORPTION OR SELECTIVE FILTRATION AND PLASMA REINFUSION

ICD-10-CM Codes that are Covered

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia

ICD-10-CM Codes that are Not Covered

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
04/12/2018 R3

This article effective 4/12/2018, combines JEA A54542 in JEB A54543 so that both JEA and JEB Contract numbers will have the same final Medicare Coverage Database Article number A54543.

10/01/2016 R2 The article is revised to add new and deleted codes effective 10/1/2016. Added E78.00 and E78.01 and deleted E78.0.
10/01/2015 R1 Noridian has updated the article on Apheresis for Hyperlipidemia to reflect the correct CPT® code for the procedure. The correct CPT® code is 36516 when apheresis is utilized for the treatment of refractory hyperlipidemia. All other aspects of the article remain the same.
Noridian will accept the incorrect CPT® code (36514) that was originally listed until October 1, 2015.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
04/02/2018 04/12/2018 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • apheresis
  • therapeutic
  • hypercholesterolemia
  • Apheresis Therapeutic Pheresis
  • 110.14