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    v1.0.31
    OpenPayerPolicy UpdatesHematology/OncologyCigna Photopheresis Coverage Update | OpenPayer
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    CurrentCignaPolicy 0320

    Extracorporeal Photopheresis

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    This policy governs the use of extracorporeal photopheresis under Cigna-administered health benefit plans. Coverage determinations must also consider the applicable benefit plan, laws and regulations, relevant coverage materials, and the specific facts of each request.

    Policy Summary
    PayerCigna
    PolicyExtracorporeal Photopheresis
    Policy CodePolicy 0320
    Change TypeAdministrative revisionpolicy reinstated
    Effective DateNovember 15, 2026
    Next Review DateAugust 15, 2027
    Key ActionSubmit the most appropriate current codes along with covered diagnosis and procedure codes.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4Covered indication categories
    15Listed not-medically-necessary indications
    36522Covered CPT code
    I / 1BErythrodermic CTCL ASA classification
    III-IV

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Uncertain, ineffective, or harmful indications

    Medical Necessity and Coverage Criteria

    Medically Necessary Indications

    Extracorporeal photopheresis is considered medically necessary for ANY of the following indications:

    Covered indications

    • Erythrodermic CTCL: Erythrodermic cutaneous T-cell lymphoma, including mycosis fungoides and Sézary syndrome.
    • GVHD: Acute or chronic graft-versus-host disease.
    • Cardiac transplantation for rejection prophylaxis or cellular or recurrent rejection.
    • Lung transplantation for bronchiolitis obliterans syndrome or chronic lung allograft dysfunction.

    Not Medically Necessary Indications

    Extracorporeal photopheresis is considered not medically necessary for ANY other indication, including the following:

    Not medically necessary indications

    • Other solid-organ graft rejection: Solid organ graft rejection not listed as covered.
    • Autoimmune diseases, including multiple sclerosis, systemic sclerosis, type 1 diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, psoriasis, and pemphigus.
    • Atopic dermatitis.
    • Crohn's disease.
    • Chronic B cell leukemia.

    Established and Medically Necessary Indications

    ECP is medically necessary or established for select indications supported by professional society recommendations and established clinical use:

    Established ECP indications: The requested ECP treatment is for one of the following indications: erythrodermic cutaneous T-cell lymphoma, including mycosis fungoides or Sézary syndrome; acute graft-versus-host disease; chronic graft-versus-host disease; cellular or recurrent cardiac transplant rejection; cardiac transplant rejection prophylaxis; bronchiolitis obliterans syndrome after lung transplantation; or chronic lung allograft dysfunction after lung transplantation.

    The American Society for Apheresis classifies erythrodermic CTCL as Category I and the GVHD, cardiac-transplantation, and lung-transplantation indications as Category II.

    Extracorporeal photopheresis (ECP) is not medically necessary for any indication other than the four covered categories: erythrodermic cutaneous T-cell lymphoma, acute or chronic graft-versus-host disease, specified cardiac-transplantation indications, and specified lung-transplantation indications.

    Coverage for the select indications reflects established clinical use and endorsement by recognized professional societies. The 2023 American Society for Apheresis guideline classifies ECP as Category I (first-line) for erythrodermic CTCL, including mycosis fungoides and Sézary syndrome, and as Category II (second-line) for acute or chronic GVHD, cellular or recurrent cardiac rejection, cardiac-rejection prophylaxis, bronchiolitis obliterans syndrome, and chronic lung allograft dysfunction. The National Comprehensive Cancer Network also includes ECP among recommended treatment options for mycosis fungoides and Sézary syndrome.

    The following are considered not medically necessary: solid-organ graft rejection not otherwise listed as covered; autoimmune diseases such as multiple sclerosis, systemic sclerosis, type 1 diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, psoriasis, and pemphigus; atopic dermatitis; Crohn's disease; chronic B-cell leukemia; chronic obstructive bronchitis; eosinophilic fasciitis; hepatitis C; HIV; myasthenia gravis; nephrogenic fibrosing sclerosis or dermopathy; nephrogenic peritonitis; non-erythrodermic mycosis fungoides; prevention of restenosis after PTCA; and composite tissue allotransplantation.

    For indications outside the covered CTCL, GVHD, cardiac-transplantation, and lung-transplantation categories, safety and efficacy have not been established. The policy cites the absence of supportive professional-society recommendations, insufficient peer-reviewed evidence, and lack of routine adoption as standard of care. Other conditions may be classified by the American Society for Apheresis as Category III, reflecting an uncertain role, or Category IV, reflecting evidence that apheresis is ineffective or potentially harmful.

    Covered Procedure Codes

    Considered Medically Necessary CPT CodeCPTCovered
    36522Photopheresis, extracorporeal

    Billing and Coverage Decision Guidance

    Billing Rule

    Use current, appropriate billing codes

    Submit the most appropriate codes in effect as of the submission date and follow the applicable policy criteria, including covered diagnosis and procedure codes.

    Denial Risk

    Submit covered codes and diagnoses

    Claims may be denied when they are not accompanied by covered procedure or diagnosis codes, or when services are billed for conditions or diagnoses not covered under the policy.

    Denial Risk

    Therapy Overview

    Extracorporeal photopheresis (ECP) is a cell-based immunomodulatory apheresis therapy. Blood is removed from the patient, white blood cells are isolated, exposed outside the body to a photoactive compound and ultraviolet A light, and then returned to the patient during the same treatment. The FDA approved ECP in 1998 for cutaneous T-cell lymphoma; the policy also recognizes established use for selected GVHD, cardiac-transplantation, and lung-transplantation indications.

    ECP and Apheresis Classification Definitions

    Extracorporeal photopheresis (ECP)
    ProcedureA therapeutic procedure in which the buffy coat is separated from the patient's blood, treated extracorporeally with a photoactive compound (e.g., psoralens), exposed to ultraviolet A light, and subsequently reinfused during the same procedure.
    ASA Category I
    Treatment roleApheresis is accepted as first-line therapy, either as a primary standalone treatment or in conjunction with other modes of treatment.
    ASA Category II
    Treatment roleApheresis is accepted as second-line therapy, either as a standalone treatment or in conjunction with other modes of treatment.

    Role of ECP in Treatment

    First-Line Therapy

    ECP is accepted as first-line therapy when the following indication is present:

    ASA Category I indication: The patient has erythrodermic cutaneous T-cell lymphoma, including mycosis fungoides or Sézary syndrome, for which ECP is accepted as first-line therapy either alone or with other treatment modalities.

    ASA classification: Category I, Grade 1B.

    Second-Line Therapy

    ECP is accepted as second-line therapy when the following indication is present:

    ASA Category II indication: The patient has an indication for which ECP is accepted as second-line therapy, including acute or chronic graft-versus-host disease, cellular or recurrent cardiac rejection, cardiac rejection prophylaxis, bronchiolitis obliterans syndrome, or chronic lung allograft dysfunction.

    ASA classifications are Category II, with grades 1B, 2A, or 1C depending on the indication.

    Covered Indication Regimens

    IndicationRegimenCoverage
    Erythrodermic cutaneous T-cell lymphoma, including mycosis fungoides and Sézary syndromeExtracorporeal photopheresisCovered
    Policy Summary
    PayerCigna
    PolicyExtracorporeal Photopheresis
    Policy CodePolicy 0320
    Change TypeAdministrative revisionpolicy reinstated
    Effective DateNovember 15, 2026
    Next Review DateAugust 15, 2027
    Key ActionSubmit the most appropriate current codes along with covered diagnosis and procedure codes.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCovered Procedure CodesBilling and Coverage Decision GuidanceTherapy OverviewECP and Apheresis Classification DefinitionsRole of ECP in TreatmentCovered Indication Regimens
    Chronic obstructive bronchitis.
  1. Eosinophilic fasciitis.
  2. Hepatitis C.
  3. HIV: Human immunodeficiency virus.
  4. Myasthenia gravis.
  5. Nephrogenic fibrosing sclerosis or dermopathy.
  6. Nephrogenic peritonitis.
  7. Non-erythrodermic mycosis fungoides.
  8. Post-PTCA restenosis prevention: Prevention of restenosis after percutaneous transluminal coronary angioplasty.
  9. Composite tissue allotransplantation.

    10. Indication is outside covered conditions

    ECP is considered not medically necessary when requested for an indication other than erythrodermic CTCL, acute or chronic GVHD, specified cardiac transplantation indications, or specified lung transplantation indications. The policy states that safety and efficacy for all other indications have not been established.

    Denial Risk

    Listed non-covered indication

    Requests for listed non-covered indications are considered not medically necessary, including non-erythrodermic mycosis fungoides, solid-organ graft rejection not listed as covered, autoimmune or dermatologic diseases, and other specified conditions.

    • Non-erythrodermic mycosis fungoides
    • Solid-organ graft rejection not listed as covered
    • Autoimmune diseases, including systemic sclerosis, type 1 diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, psoriasis, and pemphigus
    • Atopic dermatitis, Crohn's disease, chronic B cell leukemia, chronic obstructive bronchitis, eosinophilic fasciitis, hepatitis C, HIV, myasthenia gravis, nephrogenic fibrosing sclerosis or dermopathy, nephrogenic peritonitis, prevention of restenosis after PTCA, and composite tissue allotransplantation
    Denial Risk

    Indication lacks established evidence or guideline support

    ECP for indications other than the established select indications is at risk of noncoverage because safety and efficacy have not been established, supportive professional-society recommendations are absent, peer-reviewed evidence is insufficient, and the therapy is not routinely adopted as standard of care.

    Denial Risk

    ASA Category III or IV indication

    ECP for indications classified by the American Society for Apheresis as Category III or Category IV is not supported. Category III means the optimum role of apheresis is not established and treatment decisions should be individualized; Category IV reflects published evidence that apheresis is ineffective or potentially harmful.

    ASA Category III
    Treatment roleThe optimum role of apheresis therapy is not established; decision making should be individualized.
    ASA Category IV
    Treatment rolePublished evidence demonstrates or suggests that apheresis is ineffective or harmful.