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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 9.2
Issue Date:  June 30, 1993
Authority:  32 CFR 199.4(b)(2) and (c)(2)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Photopheresis is a type of plasmapheresis during which white blood cells and some plasma is exposed to Ultraviolet (UV) light before being returned to the patient.
Photopheresis is covered for the following:
3.1  The treatment of skin manifestations of Cutaneous T-Cell Lymphoma (CTCL) in persons who have not been responsive to other forms of treatment.
3.2  The prevention of rejection in cardiac transplantation.
3.3  Extracorporeal photopheresis for the treatment of Bronchiolitis Obliterans Syndrome (BOS) that is refractory to immunosuppressive drug treatment may be considered for cost-sharing under the rare disease policy as described in Chapter 1, Section 3.1.
3.4  For other indications when reliable evidence supports that photopheresis is safe, effective and comparable or superior to standard care (proven).
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