Currentblue cross blue shield - south dakotaPolicy N/A

Therapeutic Plasmapheresis or Plasma Exchange

Defines medical necessity and investigational indications for therapeutic plasmapheresis/plasma exchange (PE) and describes clinical background, intended settings, and evidence basis for use; applies to Wellmark/Blue Cross Blue Shield - South Dakota determinations of coverage for members.

Policy Summary

Payerblue cross blue shield - south dakota

PolicyTherapeutic Plasmapheresis or Plasma Exchange

Policy CodePolicy N/A

Change TypeAnnual review (no material clinical changes)

Effective DateFeb 1, 2000

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements against contract terms and the CMS NCD when requesting plasmapheresis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleGuideline sources cited

1A–2CRecommendation strength range

ManyIndications listed

OutpatientSetting

2024Literature review up to

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Coverage Criteria for Therapeutic Plasmapheresis / Plasma Exchange

Medically Necessary and Investigational Indications

Therapeutic plasmapheresis or plasma exchange (PE) may be considered medically necessary for any of the following conditions:

Medically necessary indications list: Acute disseminated encephalomyelitis (ADEM) — steroid refractory; Acute liver failure in individuals bridging to liver transplantation; Acute inflammatory demyelinating polyradiculoneuropathy (Guillain‑Barre syndrome); Acute idiopathic transverse myelitis — steroid refractory; Anti‑glomerular basement membrane disease (Goodpasture's) — including diffuse alveolar hemorrhage (DAH) or dialysis independence; ANCA‑associated rapidly progressive glomerulonephritis; Autoimmune hemolytic uremic syndrome — severe cold agglutinin; Catastrophic antiphospholipid syndrome (CAPS); Chronic acquired demyelinating polyneuropathies (IgG, IgA, IgM related); Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); Severe/symptomatic cryoglobulinemia; Familial hypercholesterolemia; Recurrent focal segmental glomerulosclerosis (FSGS) in kidney transplant; HELLP syndrome; Hyperviscosity syndromes associated with monoclonal gammopathies (e.g., multiple myeloma, Waldenstrom macroglobulinemia); Lambert‑Eaton myasthenic syndrome; Multiple myeloma cast nephropathy with acute renal failure; Multiple sclerosis — adjunctive for exacerbations in relapsing forms or treatment of fulminant steroid‑refractory CNS demyelinating disease; Mushroom (Amanita) poisoning; Myasthenia gravis; Neuromyelitis optica (Devic's disease) — acute attack/relapse; N‑methyl‑D‑aspartate (NMDAR) antibody encephalitis; Paraproteinemic demyelinating neuropathies with MGUS; Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) — exacerbation; Pemphigus vulgaris as second‑line therapy resistant to standard treatments; Refsum disease; Post‑transfusion purpura; Progressive multifocal leukoencephalopathy (PML) associated with natalizumab; Steroid‑responsive encephalopathy associated with autoimmune thyroiditis (Hashimoto encephalopathy); Systemic lupus erythematosus (SLE) with severe complications (e.g., DAH, thrombotic microangiopathy, hyperviscosity, cryoglobulinemia, CNS involvement); Thrombotic microangiopathy due to Factor H autoantibody and certain drug‑associated TMA (eg, ticlopidine); Thrombotic thrombocytopenic purpura (TTP); Thyroid storm with severe symptoms refractory to first‑line measures; Transplantation indications including HLA desensitization for HSCT and solid organ transplant desensitization/antibody‑mediated rejection; Voltage gated potassium channel antibody‑related diseases; Fulminant Wilson disease

Full enumerated list per policy

Guideline-based covered indications

Covered when aligned with guideline-based indications and ASFA category/grade recommendations.

Guideline-supported indications: Therapeutic apheresis/TPE is covered when use is consistent with specialty guideline recommendations and the ASFA category/grade for the specific condition (examples include AIDP/Guillain‑Barre Syndrome as primary treatment [ASFA Category I, Grade 1A; AAN Level A]; CIDP as short‑term treatment [AAN Level A]; steroid‑refractory ADEM [ASFA Category II, Grade 2C]; and acute liver failure bridging to transplant with TPE‑HV [ASFA Category I, Grade 1A/2B]).

Documentation should reference the applicable guideline and specific clinical context.

Unestablished or harmful indications

Not covered or considered investigational when evidence is inadequate, conflicting, or shows harm.

Unestablished/harmful indications: Use of plasmapheresis/PE for conditions where evidence is not established, is conflicting, or indicates ineffectiveness or potential harm (including conditions categorized by ASFA as Category IV) is considered investigational/not supported. Examples are enumerated in the policy and include (but are not limited to) systemic amyloidosis, amyotrophic lateral sclerosis, acute liver failure for liver regeneration or AFLP (except bridging to transplant), anti‑GBM disease that is dialysis‑dependent without DAH, aplastic anemia, asthma, refractory atopic dermatitis, warm autoimmune hemolytic anemia, autoimmune retinopathy, burn shock resuscitation, neonatal cardiac lupus, many chronic CNS demyelinating diseases except specified indications, chronic fatigue syndrome, Rasmussen encephalitis, coagulation factor inhibitors, complex regional pain syndrome, dermatomyositis/polymyositis, idiopathic dilated cardiomyopathy, erythropoietic protoporphyria with liver disease, most native FSGS, Henoch‑Schönlein purpura, many forms of HUS, HIT pre‑CPB or HITT, HLH/macrophage activation syndrome, hypertriglyceridemia‑associated pancreatitis, immune complex RPGN, refractory ITP, IgA nephropathy, inclusion body myositis, inflammatory bowel disease, nephrogenic systemic fibrosis, overdose/envenomation/poisoning (except listed poisonings such as Amanita), paraneoplastic neurologic syndromes, POEMS, pruritus from hepatobiliary disease, psoriasis, pure red cell aplasia, red cell alloimmunization in pregnancy, rheumatoid arthritis, schizophrenia, scleroderma, sepsis with multiorgan failure, status epilepticus, stiff‑person syndrome, sudden sensorineural hearing loss, Sydenham's chorea, and many others as listed in the policy.

Investigational (insufficient evidence) — IRB/ethics review desirable if considered (ASFA Category IV).

Covered indications (guideline-based list)

Covered indications and recommended modality/grade — each entry lists disease, recommended apheresis modality, indication context, category, and grade.

Selected indications examples: Acute disseminated encephalomyelitis (ADEM) — Modality: TPE; Indication: Steroid‑refractory; Category: II; Grade: 2C. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP/Guillain‑Barre Syndrome) — Modality: TPE; Indication: Primary treatment; Category: I; Grade: 1A. Acute liver failure — Modality: TPE‑HV; Indication: Bridging to liver transplantation in select individuals; Category: I; Grade: 1A/2B. Thrombotic thrombocytopenic purpura (TTP) — Modality: TPE; Category: I; Grade: 1A. Myasthenia gravis — Modality: TPE/DFPP/IA; Indication: Acute short‑term treatment; Category: I; Grade: 1B. Familial hypercholesterolemia — Modality: TPE; Indication: Selected patients; Category: II; Grade: 1B. Recurrent FSGS in kidney transplant — Modality: TPE; Indication: Recurrent disease post‑transplant; ASFA categories/grades per guideline. Transplant desensitization and antibody‑mediated rejection (solid organ and HLA desensitization for HSCT) — Modality: TPE/IA; Indication: Desensitization/AMR; Category and Grade per ASFA entries. Vasculitis (ANCA‑associated, IgA/crescentic RPGN and other severe vasculitides) — Modality: TPE; Indication: Severe renal or extrarenal disease; Categories and Grades per ASFA guidance.

See full guideline tables in policy for complete modality, category, and grade assignments.

ASFA-guided indication groups

ASFA guideline recommendation categories and grades listed for specific transplant and vasculitis indications (as summarized):

Transplantation indications: Liver transplantation (ABOi desensitization — living and deceased donor, antibody‑mediated rejection) — Modality: TPE; ASFA Category: III; Grade: 2C. Lung transplantation — Modality: TPE; Indication: Antibody‑mediated rejection/desensitization; ASFA Category: III; Grade: 2C. HSCT HLA desensitization and solid organ transplant antibody‑mediated rejection — Modality: TPE/IA; ASFA categories/grades as listed in ASFA guidance.

ASFA tables provide specific category/grade per transplant type.

Vasculitis indications: ANCA‑associated vasculitis (eg, microscopic polyangiitis, granulomatosis with polyangiitis) — Modality: TPE; Category: III; Grade: 1B (selected entries). IgA vasculitis including crescentic RPGN and severe extrarenal disease — Modality: TPE; Category: III; Grade: 2C. Other vasculitides (eg, hepatitis B polyarteritis nodosa, Kawasaki disease, MIS‑C) — Modality: TPE; Categories II–III; Grades 2C in many entries.

Refer to ASFA guideline tables for full details.

Other specific indications: Voltage gated potassium channel antibody‑related diseases — Modality: TPE/IA; ASFA Category: II; Grade: 1B. Fulminant Wilson disease — Modality: TPE; ASFA Category: I; Grade: 1C.

NCCN recommendations for plasma cell disorders

NCCN guidance for plasma cell disorders:

Multiple Myeloma hyperviscosity: Plasmapheresis recommended as adjunctive therapy for symptomatic hyperviscosity.

NCCN statement

Waldenstrom macroglobulinemia: Plasmapheresis recommended for symptomatic hyperviscosity and prior to rituximab‑containing regimens in patients with IgM > 4000 mg/dL; monitor IgM thereafter and consider repeat plasmapheresis for recurrent symptoms or IgM > 4000 mg/dL while on rituximab. Red blood cell transfusion, if indicated, should be done after plasmapheresis to avoid added hyperviscosity.IgM > 4000 mg/dL

NCCN statement

Therapeutic plasmapheresis or plasma exchange (PE) is designated as investigational for conditions not specifically listed as medically necessary. The policy enumerates a broad investigational list that includes, but is not limited to, indications such as acute liver failure for liver regeneration (except bridging to transplant), systemic amyloidosis, ALS, dialysis‑dependent anti‑GBM disease without diffuse alveolar hemorrhage, aplastic anemia, asthma, refractory atopic dermatitis, warm autoimmune hemolytic anemia, many central nervous system demyelinating diseases (unless specifically indicated), inflammatory bowel disease, and numerous other disorders. Use for these conditions is considered investigational because the evidence is insufficient to determine net health benefit or may show lack of efficacy or potential harm.

The policy references ASFA category definitions and specifically identifies situations corresponding to ASFA Category IV — disorders where apheresis is ineffective or may be harmful — as not supported by the evidence review. When literature or guideline assessments place an indication in ASFA Category IV, the policy treats apheresis as unestablished or potentially harmful and recommends that such uses be approached cautiously; Institutional Review Board or ethics committee review is desirable if apheresis is undertaken in these circumstances.

Within the extracted sections there are multiple listings of conditions classified under ASFA Categories III–IV or otherwise described as unestablished, but the policy text does not present an explicit, separate payer exclusion statement in those chunks. Instead, the document lists many investigational/unestablished indications (ASFA Category III or IV) and states that therapeutic plasmapheresis/PE is considered investigational for conditions not specified as medically necessary.

Review of the provided chunks shows no explicit exclusions formatted as a standalone payer exclusion section within the cited excerpts. The content instead documents guideline categorizations (ASFA categories III–IV and NCCN recommendations) and enumerates investigational and medically necessary indications without a separate “excluded” label in these chunks.

The policy states that plasmapheresis/PE for indications lacking established evidence or for which studies indicate lack of benefit or potential harm is considered investigational (and in the policy framework may be treated as not supported). Procedures used in such contexts carry increased risk of denial and should be justified with appropriate documentation and, where appropriate, ethics oversight.

A review of chunks 36–55 (as represented in the extracted material) did not reveal explicit statements labeled “not medically necessary” in that span. Instead, the document uses the investigational/unestablished language and ASFA category descriptors (III–IV) to indicate when plasmapheresis/PE is not supported by the evidence, while reserving formal not‑medically‑necessary determinations to the policy’s investigational listings.

Covered Regimens and Indication Examples

Indication	Regimen / Rationale	Coverage
Multiple myeloma cast nephropathy with acute renal failure	Therapeutic plasmapheresis / plasma exchange to remove pathogenic plasma proteins (light chains) contributing to cast nephropathy and acute renal failure	Covered when used to remove pathogenic proteins contributing to cast nephropathy in the setting of acute renal failure, consistent with policy-listed indications

Indication	Regimen / Rationale	Coverage
Hyperviscosity syndromes associated with monoclonal gammopathies (e.g., Waldenstrom's macroglobulinemia)	Plasmapheresis / plasma exchange to reduce serum viscosity and remove circulating paraproteins contributing to symptomatic hyperviscosity; timing may be guided by NCCN recommendations (e.g., prior to rituximab when IgM > 4000 mg/dL)	Covered for symptomatic hyperviscosity syndromes associated with monoclonal gammopathies per policy and NCCN guidance

Coding and Billing References

Coding table referencedmixed

No codes listed

Guideline modality mentions (no billing codes in excerpt)mixed

No codes listed

Covered CPT CodesCPTCovered

36514

Therapeutic apheresis; for plasmapheresis.

HCPCSHCPCS

None	No HCPCS codes listed

RevenueRevenue

None	No Revenue codes listed

Place of Servicemixed

Place of Service

Outpatient/Inpatient

IgM level threshold — timing consideration for plasmapheresis

IgM thresholdIgM > 4000 mg/dL

Clinical contextUsed to time plasmapheresis before rituximab-containing regimens in Waldenstrom macroglobulinemia

Monitoring recommendationMonitor IgM closely thereafter and consider repeat plasmapheresis if symptomatic hyperviscosity recurs or IgM > 4000 mg/dL while on rituximab

CPT 36514 definition — therapeutic apheresis / plasmapheresis code

CPT code36514

Provider Actions: Authorization, Documentation, and Billing

Prior Authorization

Prior Approval / Benefit Verification

Prior approval: Benefit determinations depend on contract language and member verification. Verify member benefits and contract exclusions before scheduling services; Wellmark determines medical necessity only if the benefit exists and no contract exclusions apply.

Prior approval: Not applicable (see policy header) — verify member-specific prior approval requirements as some contracts may require prior authorization even if policy-level prior approval is listed as not applicable.
Confirm eligibility and benefit limits at time of service.

Documentation Required

Verify Prior Authorization Against CMS NCD

Verify prior authorization against the Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) for Apheresis (NCD 110.14) when applicable. CMS NCD language may inform coverage decisions and influence denial risk; payer-specific rules override only when documented in the contract or policy.

Clinical Background and Evidence Basis

Plasmapheresis and plasma exchange (PE/TPE) function by physically removing a patient’s plasma and the pathogenic plasma constituents it contains (for example, pathogenic antibodies, immune complexes, complements, and certain proteins or toxins). Because removed factors may be rapidly re‑produced, the effect is typically symptomatic or temporizing rather than curative. Plasma exchange differs from small‑volume plasmapheresis in that PE involves large‑volume plasma removal and requires replacement fluid (such as albumin) to maintain intravascular volume. The clinical rationale for PE is to acutely lower circulating pathogenic substances to improve symptom burden or alter the immediate disease course, which is why PE is most effective in acute, self‑limited diseases and fulminant exacerbations where rapid removal of harmful plasma components can meaningfully change outcomes.

Definitions and Grading

Apheresis definition — removal and return of blood components

DefinitionApheresis is the removal of blood from a subject with separation of a portion of the blood to be retained while the rest is returned to the donor

PurposeGeneral term for procedures that separate and remove selected blood components

SettingProcedures are typically performed in outpatient settings including blood banks, dialysis centers, and hospitals (see background)

Plasmapheresis definition — smaller plasma removal, typically <15% blood volume

DefinitionPlasmapheresis removes a smaller amount of plasma, usually less than 15% of the patient’s blood volume

Replacement fluidTypically does not require replacement of removed plasma due to small volume removed

Biomarker Thresholds and Laboratory Guidance

IgM biomarker threshold — IgM > 4000 mg/dL as a timing consideration for plasmapheresis

IgM timing thresholdIgM > 4000 mg/dL

Use caseThreshold used to guide plasmapheresis before rituximab-containing regimens in Waldenstrom macroglobulinemia to prevent hyperviscosity

Follow-upMonitor IgM closely after therapy and consider repeat plasmapheresis if symptomatic hyperviscosity recurs or IgM exceeds 4000 mg/dL while on rituximab

Policy Revision History

Policy Summary

Payerblue cross blue shield - south dakota

PolicyTherapeutic Plasmapheresis or Plasma Exchange

Policy CodePolicy N/A

Change TypeAnnual review (no material clinical changes)

Effective DateFeb 1, 2000

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements against contract terms and the CMS NCD when requesting plasmapheresis.

SourceLink

On This Page

ASFA summarized recommendations.

Therapeutic apheresis; for plasmapheresis

Place of serviceOutpatient/Inpatient (use appropriate setting when reporting)

Check CMS NCD 110.14 at https://www.cms.gov/medicare-coverage-database.
Document any CMS-based justification used in authorization requests.

Billing Rule

Reporting and Coding

Reporting requirement: Use CPT 36514 to report therapeutic plasmapheresis (plasmapheresis/therapeutic apheresis). Ensure appropriate place of service (inpatient/outpatient) and ICD-10 diagnosis coding that supports medical necessity.

Primary CPT: 36514 — Therapeutic apheresis; for plasmapheresis.
Include supporting diagnosis codes and facility/place information on the claim.

Prior Authorization

Benefit / Contract Verification

Benefit/contract verification required: Coverage determinations are based on the applicable contract language in effect at the time of service. Individual member benefits must be verified and federal programs (FEP/Medicare) may follow different rules.

Verify member-specific benefits, exclusions, and any contract limitations before treatment.
If benefit is absent or excluded, do not proceed under Wellmark medical necessity determination.

Denial Risk

Non‑established or Harmful Indications

Non-established or potentially harmful indications: Do not authorize therapeutic plasmapheresis for conditions where evidence is insufficient or demonstrates potential harm. The policy lists investigational/unproven uses and notes published literature indicating possible ineffectiveness or harm for some indications.

Therapeutic plasmapheresis considered investigational for all conditions not listed as medically necessary in the policy.
Document rationale when requesting authorization for uncommon indications and include supporting literature.

Denial Risk

CMS NCD Influence on Denial Risk

CMS NCD influences denial risk: The CMS National Coverage Determination for apheresis may guide denials or approvals. Align documentation with NCD criteria where applicable and note that CMS guidance may be considered when reviewing claims.

Reference NCD 110.14 in clinical justification when applicable.
Be aware that CMS guidance can increase denial risk if documentation does not meet NCD expectations.

Denial Risk

Coding‑based Denial Risk

Coding-based denial risk: Incorrect or incomplete CPT/HCPCS/Revenue/ICD coding may lead to claim denials. Use CPT 36514 for plasmapheresis and ensure diagnosis and place-of-service codes support medical necessity on the claim.

Use CPT 36514; include accurate ICD-10 diagnosis that matches the listed medically necessary indications.
Confirm place of service (outpatient/inpatient) and facility revenue codes as required.

Documentation Required

Clinical Context and Procedural Setting

Clinical context and setting documentation: Document the clinical context (e.g., indication, severity, timing relative to transplant) and setting (outpatient vs inpatient). Procedures should be performed by trained clinicians in settings able to manage emergencies.

For solid organ transplantation AMR/ABMR, document that plasmapheresis is performed typically within the first year post‑transplant.
Document that procedure location (blood bank, dialysis center, hospital clinic, or physician office) can manage potential complications.

Documentation Required

Document Clinical Indication and Therapeutic Intent

Clinical indication and therapeutic intent: Authorization requests must state the therapeutic intent to remove harmful plasma components, disease severity, prior therapy failures, and specific indication from the policy's medically necessary list (e.g., TTP, AMR, symptomatic hyperviscosity).

State intent: removal of pathogenic antibodies/proteins/complements and expected clinical goal.
Include prior therapies tried and why plasmapheresis is indicated (e.g., second‑line for pemphigus vulgaris after failure of standard therapy).

Documentation Required

Documentation Expectations (not explicit in source)

No explicit documentation requirements present in extracted sections: The source does not list a formalized set of documentation items beyond clinical indication, prior therapy, timing, and rationale. Include guideline citations and detailed clinical notes to strengthen requests.

Provide clinical notes, labs, prior treatment history, and literature/guideline support as available.
If payer requires specific forms or checklists, obtain and submit them with the authorization.

Documentation Required

Document Guideline‑based Indication

Document guideline‑based indication: When applicable, cite relevant guidelines (American Society for Apheresis, AAN, ASFA, NCCN) and CMS NCD to support medical necessity in prior authorization and claims.

Cite ASFA/Practice Guideline and Position Statements and AAN recommendations for neurologic indications.
For multiple myeloma and Waldenstrom's/Waldenstrom macroglobulinemia, cite NCCN guidance regarding hyperviscosity and timing relative to rituximab.

Note

Policy Documentation and Contact

Policy documentation / contact: For policy history, revisions, or to submit new information for review, use the Wellmark Medical Policy Analyst contact information and reference the policy history in authorization communications.

Policy history available (annual reviews and revisions listed through March 2025).
Submit new evidence or inquiries to: Wellmark Blue Cross and Blue Shield Medical Policy Analyst PO Box 9232 Des Moines, IA 50306-9232.

Step Therapy

Step Therapy and Alternative Therapies

Step therapy requirements and alternatives: Plasmapheresis is considered second‑line for some diagnoses (e.g., pemphigus vulgaris after failure of dapsone, corticosteroids, immunosuppressants). When applicable, document failed standard therapies and consider guideline‑based alternatives such as IVIG, steroids, and immunosuppressants prior to authorization.

List prior therapies attempted and duration of treatment.
Consider and document alternatives (IVIG, corticosteroids, azathioprine, cyclosporine) when appropriate.

Step Therapy

Absent Universal Step‑therapy Requirements

No step therapy requirements specified in extracted sections: Aside from condition‑specific notes (e.g., pemphigus vulgaris second‑line), the policy excerpts do not mandate universal step therapy pathways. Verify plan‑specific requirements during benefit checks.

If plan-level step therapy exists, follow that process; otherwise include prior therapy history in requests.

Documentation Required

Timing Relative to Therapy (NCCN)

Timing relative to therapy (NCCN): For Waldenstrom macroglobulinemia and multiple myeloma, document plasmapheresis timing — use for symptomatic hyperviscosity and before rituximab‑containing regimens in patients with IgM > 4000 mg/dL per NCCN guidance.

Document pre‑rituximab plasmapheresis when IgM > 4000 mg/dL and symptomatic hyperviscosity.
Monitor and document IgM levels and symptom recurrence as part of ongoing care.

Note

Provider Actions Not Explicitly Listed in Source

Provider action: Not present in extracted sections — placeholder acknowledgement that some provider-action items were not explicitly listed in the provided excerpts. Where requirements are absent, follow general best practices: verify benefits, supply full clinical documentation, and reference relevant guidelines.

If specific authorization forms, checklists, or code lists are required by the payer, obtain and submit them.
When in doubt, contact Wellmark for clarification before performing services.

DistinctionTerm distinguished from large-volume plasma exchange which requires replacement to avoid hypovolemia

Plasma Exchange (PE) definition — large-volume plasma removal with replacement fluids

DefinitionPlasma Exchange (PE) is a procedure in which a large volume of plasma is removed and must be replaced with a substitution fluid (eg, albumin) to prevent hypovolemia

Volume considerationVolume removed is sufficient that, if not replaced, significant hypovolemia and vasomotor collapse could occur

GoalAimed at removing harmful circulating plasma components by discarding and replacing plasma

Therapeutic Plasmapheresis / Plasma Exchange (PE/TPE) — procedural description and goals

Procedure descriptionTherapeutic plasmapheresis/PE isolates plasma which is then discarded or replaced with a substitution fluid such as albumin

Primary goalRemoval of harmful plasma components (eg, pathogenic antibodies, immune complexes, toxins) to improve acute disease course or symptoms

Clinical applicationsUsed for acute, self-limited diseases or fulminant exacerbations where rapid removal of circulating pathogenic substances is beneficial

Grade 1A/1B/1C/2A/2B/2C — recommendation strength and evidence quality grading explanation

Grade 1 (A/B/C)Strong recommendation: 1A = strong recommendation, high quality evidence; 1B = strong recommendation, moderate quality evidence; 1C = strong recommendation, low/very low quality evidence

Grade 2 (A/B/C)Weak recommendation: 2A = weak recommendation, high quality evidence; 2B = weak recommendation, moderate quality evidence; 2C = weak recommendation, low/very low quality evidence

ImplicationsGrade 1 implies can apply to most patients without reservation; Grade 2 implies the best action may differ depending on circumstances or patient values

Therapeutic Apheresis (TPE) — definition and clinical uses summary

DefinitionTherapeutic Apheresis (TPE) is a procedure to remove plasma and replace it with substitute fluids to eliminate pathogenic plasma components

Clinical usesUsed for desensitization in transplantation, treatment of antibody-mediated rejection, vasculitis, TTP, hyperviscosity syndromes, and other immune-mediated conditions per guideline recommendations

LimitationsPrimarily symptomatic; does not address ongoing production of pathogenic factors and may be less effective for chronic conditions due to rebound production