CurrentCignaPolicy 0320

Extracorporeal Photopheresis

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This policy governs coverage of extracorporeal photopheresis (ECP) under Cigna-administered health benefit plans, identifying medically necessary and not medically necessary indications and covered procedure coding requirements.

Policy Summary

PayerCigna

PolicyExtracorporeal Photopheresis

Policy CodePolicy 0320

Change TypeReinstatedno clinical policy statement changes

Effective DateNov 15, 20267d

Next Review DateAug 15, 2027

Key ActionSubmit ECP claims with covered procedure code 36522 and a covered indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Covered indication groups

15Not medically necessary indication examples

36522Covered procedure code

I-IIASA classification range

Medical Necessity Criteria

Medically Necessary Indications

Covered when ANY one of the following indications is present:

Medically necessary 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/recurrent rejection.
Lung transplantation for bronchiolitis obliterans syndrome or chronic lung allograft dysfunction.

Not Medically Necessary Indications

Not medically necessary when ANY other indication is present, including the following listed conditions:

Not medically necessary indications

Unlisted solid-organ rejection: Solid organ graft rejection not otherwise listed as covered.
Autoimmune diseases, including multiple sclerosis, systemic sclerosis, type 1 diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, psoriasis, and pemphigus.
Other listed conditions: 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; or composite tissue allotransplantation.

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

ECP is not medically necessary for 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, or for atopic dermatitis and Crohn's disease.

Other non-covered indications include 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.

Covered Procedure Coding

Considered Medically Necessary when criteria in the applicable policy statements listed above are metCPTCovered

36522

Photopheresis, extracorporeal

Claims and Billing Guidance

Denial Risk

Unsupported Indication or Coding

Claims for extracorporeal photopheresis (ECP) are reimbursable only when the service meets the applicable medical-necessity criteria and is submitted with covered diagnosis and procedure codes. Claims for unsupported indications, noncovered conditions, or services submitted without covered codes will be denied as not covered.

Use the most appropriate codes in effect on the date of submission.
Submit CPT 36522 (photopheresis, extracorporeal) only for covered indications and when the applicable policy criteria are met.
Reimbursement is not allowed when ECP is billed for conditions or diagnoses not covered under the policy.

Therapy Background

Extracorporeal photopheresis (ECP) is an apheresis-based immunomodulatory therapy. During treatment, blood is removed from the patient, white blood cells are isolated and exposed to a photoactive compound and ultraviolet A light, and the treated blood is returned to the patient during the same procedure.

Key Definitions

Extracorporeal photopheresis (ECP)

Procedure typeA therapeutic, cell-based immunomodulatory procedure and a type of apheresis.

Blood processingBlood or the buffy coat is separated from the patient's blood.

Extracorporeal treatmentThe separated blood component is treated extracorporeally with a photoactive compound, such as psoralens, and exposed to ultraviolet A light.

Completion of procedureThe treated blood component is subsequently reinfused to the patient during the same procedure.

ASA Category I

ClassificationASA Category I.

Therapeutic roleApheresis is accepted as first-line therapy.

Use as primary treatmentApheresis may be used as a primary standalone treatment.

Combination useApheresis may be used in conjunction with other modes of treatment.

ASA Category II

ClassificationASA Category II.

Therapeutic roleApheresis is accepted as second-line therapy.

Use as standalone treatmentApheresis may be used as a standalone treatment.

Combination useApheresis may be used in conjunction with other modes of treatment.

Therapy-Line Classifications

First-Line | Second-Line

For covered indications, the applicable treatment role is classified as first-line or second-line according to ASA guidance:

ASA-supported ECP treatment role: For covered indications, ASA classifies ECP as Category I first-line therapy or Category II second-line therapy, depending on the indication.

Policy Summary

PayerCigna

PolicyExtracorporeal Photopheresis

Policy CodePolicy 0320

Change TypeReinstatedno clinical policy statement changes

Effective DateNov 15, 20267d

Next Review DateAug 15, 2027

Key ActionSubmit ECP claims with covered procedure code 36522 and a covered indication.

SourceLink

On This Page

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Extracorporeal Photopheresis

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Medical Necessity Criteria

Medically Necessary Indications

Covered when ANY one of the following indications is present:

Medically necessary 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/recurrent rejection.
Lung transplantation for bronchiolitis obliterans syndrome or chronic lung allograft dysfunction.

Not Medically Necessary Indications

Not medically necessary when ANY other indication is present, including the following listed conditions:

Not medically necessary indications

Unlisted solid-organ rejection: Solid organ graft rejection not otherwise listed as covered.
Autoimmune diseases, including multiple sclerosis, systemic sclerosis, type 1 diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, psoriasis, and pemphigus.
Other listed conditions: 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; or composite tissue allotransplantation.

Claims and Billing Guidance

Denial Risk

Unsupported Indication or Coding

Use the most appropriate codes in effect on the date of submission.
Submit CPT 36522 (photopheresis, extracorporeal) only for covered indications and when the applicable policy criteria are met.
Reimbursement is not allowed when ECP is billed for conditions or diagnoses not covered under the policy.

Therapy Background

Key Definitions

Extracorporeal photopheresis (ECP)

Procedure typeA therapeutic, cell-based immunomodulatory procedure and a type of apheresis.

Blood processingBlood or the buffy coat is separated from the patient's blood.

Extracorporeal treatmentThe separated blood component is treated extracorporeally with a photoactive compound, such as psoralens, and exposed to ultraviolet A light.

Completion of procedureThe treated blood component is subsequently reinfused to the patient during the same procedure.

ASA Category I

ClassificationASA Category I.

Therapeutic roleApheresis is accepted as first-line therapy.

Use as primary treatmentApheresis may be used as a primary standalone treatment.

Combination useApheresis may be used in conjunction with other modes of treatment.

ASA Category II

ClassificationASA Category II.

Therapeutic roleApheresis is accepted as second-line therapy.

Use as standalone treatmentApheresis may be used as a standalone treatment.

Combination useApheresis may be used in conjunction with other modes of treatment.

Therapy-Line Classifications

First-Line | Second-Line

For covered indications, the applicable treatment role is classified as first-line or second-line according to ASA guidance:

ASA-supported ECP treatment role: For covered indications, ASA classifies ECP as Category I first-line therapy or Category II second-line therapy, depending on the indication.