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procedure in which blood is withdrawn from a donor, a portion (plasma,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.
