2.0 DESCRIPTION
Any procedure in which blood is withdrawn from
a donor, a portion (plasma, leukocytes, platelets, etc.) is separated
and retained, and the remainder is retransfused into the donor.
3.0 POLICY
Therapeutic apheresis is covered when medically
necessary and the standard of medical practice. Outlined below are
some examples of conditions for which therapeutic apheresis is indicated. The
list of indications is not all inclusive. Other indications are
covered when documented by reliable evidence as safe, effective
and comparable or superior to standard care (proven).
3.1 Myasthenia
gravis during a life-threatening crisis.
3.2 Goodpasture’s Syndrome.
3.3 Life-threatening
immune complex rheumatoid vasculitis.
3.4 Multiple myeloma (symptomatic
monoclonal gammopathy).
3.5 Waldenstrom’s macroglobulinemia.
3.6 Hypergammaglobulinemia
purpura.
3.7 Cryoglobulinemia.
3.8 Thrombotic thrombocytopenic
purpura.
3.9 Guillain-Barre syndrome.
3.10 Membranous
and proliferative nephritis (glomerulonephritis).
3.11 Chronic
myelogenous leukemia.
3.12 Chronic inflammatory demyelinating
polyneuropathy.
3.13 Familial hypercholesterolemia.
3.14 Leukapheresis
in the treatment of leukemia.
3.15 Hemolytic Uremic Syndrome
(HUS).
3.16 Hyperviscosity syndromes.
3.17 Post-transfusion
purpura.
3.18 Refsum’s disease.