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is withdrawn from a donor, a portion (plasma, leukocytes, platelets,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.