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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 9.4
Therapeutic Apheresis
Issue Date:  December 29, 1982
Authority:  32 CFR 199.4(d)(1)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
36520, 36521
Any procedure in which blood is withdrawn from a donor, a portion (plasma, leukocytes, platelets, etc.)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.
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.
Therapeutic apheresis for the treatment of desmoplastic small, round-cell tumor is unproven.
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