UnitedHealthcare Apheresis Coverage Update

Coverage and Medical Necessity Criteria

Medically necessary / Covered indications

Therapeutic apheresis is considered proven and medically necessary for the following conditions/diagnoses:

Covered indications: Acute inflammatory demyelinating polyneuropathy (primary treatment); Acute liver failure requiring high-volume therapeutic plasma exchange (TPE-HV); Anti-glomerular basement membrane disease (dialysis independent and diffuse alveolar hemorrhage); Chronic acquired demyelinating polyneuropathies (IgG/IgA/IgM-related; anti-myelin-associated glycoprotein); Chronic inflammatory demyelinating polyneuropathy; Cryoglobulinemia (second-line therapy); Cutaneous T-cell lymphoma, including erythrodermic mycosis fungoides and Sézary syndrome; Idiopathic dilated cardiomyopathy NYHA II-IV via immunoadsorption; Erythrocytosis (polycythemia vera); Familial hypercholesterolemia (homozygotes: lipoprotein apheresis; heterozygotes: lipoprotein apheresis second-line; all patients via therapeutic plasma exchange); Recurrent focal segmental glomerulosclerosis in transplanted kidney (second-line therapy); Acute and chronic graft-versus-host disease (chronic second-line); Hereditary hemochromatosis; Severe hypertriglyceridemic pancreatitis; Hyperviscosity in hypergammaglobulinemia; Inflammatory bowel disease (ulcerative colitis, Crohn's disease) via adsorptive cytapheresis

Listed indications as provided in policy

Operational note: Coverage applies to apheresis modalities appropriate to the indication (e.g., plasmapheresis/TPE, immunoadsorption, lipoprotein apheresis, cytapheresis, photopheresis) as specified in other policy sections and consistent with specialty guidance.

See modality-specific sections for device/technique details

Not medically necessary / Unproven indications

Therapeutic apheresis is considered unproven and not medically necessary for the following (non‑exhaustive) conditions:

Not medically necessary indications: Acute disseminated encephalomyelitis (ADEM); Acute liver failure and acute fatty liver of pregnancy (TPE listed here as unproven); Acute toxins/venoms/poisons; Age-related macular degeneration (dry); Alzheimer's disease (mild or moderate); Amyloidosis (systemic, dialysis-related); ANCA-associated rapidly progressive glomerulonephritis, dialysis independent; Anti-GBM disease dialysis dependent without diffuse alveolar hemorrhage; Atopic dermatitis, recalcitrant; Autoimmune dysautonomia; Autoimmune hemolytic anemia (severe WAIHA); Babesiosis (severe); Burn shock resuscitation; Cardiac neonatal lupus; Catastrophic antiphospholipid syndrome/HUS; CANOMAD/CANDA; Chronic focal encephalitis; Coagulation factor deficiency/inhibitors; Complex regional pain syndrome; FSGS (steroid resistant in native kidney via TPE or LDL apheresis); Hemophagocytic lymphohistiocytosis; Heparin-induced thrombocytopenia and thrombosis; Hyperleukocytosis (except when guideline-supported); Prevention of HTG pancreatitis relapse; Idiopathic inflammatory myopathies; IgA nephropathy; Immune checkpoint inhibitor–related adverse events; Immune thrombocytopenia, refractory; Crohn's disease via ECP (outside research); Lambert-Eaton syndrome; Malaria; Multiple sclerosis, chronic; Myasthenia gravis, long-term treatment; Myeloma cast nephropathy as standalone therapy (without concurrent chemotherapy); Nephrogenic systemic fibrosis; Neuromyelitis optica spectrum disorder (maintenance); Paraneoplastic autoimmune retinopathies/neurologic syndromes; Pemphigus vulgaris; Phytanic acid storage disease; Post-transfusion purpura; Psoriasis; Red blood cell alloimmunization (pregnancy complications); Sepsis with multiorgan failure (insufficient evidence for routine use); Sickle cell disease (unless specifically noted as proven); Steroid-responsive encephalopathy associated with autoimmune thyroiditis; Stiff-person syndrome; Sudden sensorineural hearing loss; Sydenham's chorea (routine use not supported); Systemic lupus erythematosus (severe complications); Systemic sclerosis; Thrombocytosis; Thrombotic microangiopathies (specific subtypes per guidance); Toxic epidermal necrolysis / SJS (insufficient quality evidence); Transplantation-related indications not explicitly listed as proven

Desensitization for Kidney Transplants

Covered when ALL of the following clinical conditions and treatment-context factors are present (examples supported by evidence in this section):

Desensitization for HLA-sensitized kidney transplant: Candidate is HLA-sensitized and undergoing live-donor renal transplantation with a protocol including plasmapheresis ± low-dose IVIG; transplantation is planned within days of last plasmapheresis; documentation includes planned number/frequency of sessions and timing relative to transplantationtiming crucial: transplantation within days after last treatment

Montgomery et al. reported survival benefit in 211 treated patients

Familial Hypercholesterolemia and Lipoprotein(a) Hyperlipoproteinemia

Covered when ALL of the following are met for familial hypercholesterolemia (hoFH) or severe Lp(a) hyperlipoproteinemia:

Lipoprotein apheresis in hoFH (pediatric): Genetically confirmed homozygous familial hypercholesterolemia or compound heterozygous FH with markedly elevated LDL-C despite maximally tolerated lipid-lowering therapy; documented apheresis frequency and monitoring plan; multidisciplinary management and registry/long-term follow-up when availableMarkedly elevated LDL-C (registry median untreated LDL-C ~19.2 mmol/L)

Registry data (n=50 children) show significant LDL-C reductions; NICE recommends trying lipid-modifying drug therapy before LDL apheresis in patients under 16

Hypertriglyceridemic Pancreatitis

Considered when clinician documents ALL of the following for hypertriglyceridemia-induced acute pancreatitis (HTG-AP):

Plasmapheresis for HTG-AP: Severe HTG-induced acute pancreatitis with very high triglycerides and clinical judgment that rapid triglyceride reduction may alter clinical course; documentation of failure or limitations of conventional therapy and a plan for close monitoring and supportive care; risks and limited outcome evidence discussed with patient/familyMarkedly elevated TG prompting intervention

Systematic review/meta-analysis shows faster TG reduction but no clear prognostic benefit; higher in-hospital mortality reported in some pooled observational data

Idiopathic Dilated Cardiomyopathy (DCM)

Covered when ALL of the following are present for idiopathic dilated cardiomyopathy (DCM) via immunoadsorption:

Immunoadsorption for DCM: Patient has idiopathic dilated cardiomyopathy NYHA class II–IV refractory to optimal medical therapy; immunoadsorption is provided under specialist care or in the context of monitored clinical study with objective echocardiographic and symptomatic assessment (e.g., LVEF, LV dimensions, NYHA class); documentation of expected monitoring and safety planEvidence of symptomatic and echocardiographic impairment

Meta-analysis (12 studies, n=395) reported improved LVEF and symptoms but limited safety data and heterogeneity

Inflammatory Bowel Disease (Ulcerative Colitis)

Covered when ALL of the following apply for ulcerative colitis (UC):

GMA/CAP use-cases: (1) Induction or maintenance of remission in moderate–severe UC as adjunct to conventional therapy for patients with inadequate response; (2) Intensive granulocyte/monocyte adsorptive apheresis (GMA) without corticosteroids for induction where mucosal healing is documented and a maintenance strategy is planned; evidence of disease activity indices and endoscopic mucosal healing requiredClinical activity indices and mucosal healing documented

Systematic reviews and trials (~589 patients) show low-certainty evidence of benefit as adjunctive therapy

Myasthenia Gravis, Acute

Considered when ALL of the following are present for acute myasthenia gravis exacerbation:

Plasmapheresis for acute MG: Documented acute MG exacerbation for which rapid antibody removal is clinically indicated; clinician has considered IVIG vs plasmapheresis and documented rationale if plasmapheresis chosen (speed of effect, antibody profile, prior response); monitoring plan and complication risk mitigation documentedDocumented acute exacerbation requiring rapid improvement

Meta-analysis suggests plasmapheresis yields higher odds of short-term symptomatic improvement vs IVIG but may have higher severe complication rates

Myeloma Cast Nephropathy (Light Chain Cast Nephropathy)

Covered when ALL of the following apply for multiple myeloma with cast nephropathy (used as second-line/adjunctive therapy):

Plasmapheresis for myeloma cast nephropathy: Confirmed multiple myeloma with acute kidney injury attributable to light-chain cast nephropathy; elevated serum free light chains consistent with cast nephropathy; plasmapheresis is used as an adjunct to appropriate chemotherapy (eg, bortezomib-containing regimens) with planned multiple sessions (often ≥3) and close monitoring; documentation of timing relative to chemotherapy and intended number/frequency of exchangesEvidence of cast nephropathy with elevated sFLCs and AKI

Retrospective series and some RCTs/meta-analyses show biochemical FLC reduction and potential reduction in dialysis dependence when combined with chemotherapy; systematic review shows no benefit when used as standalone therapy

Neuromyelitis Optica Spectrum Disorder (NMOSD), Acute or Relapse

Considered when ALL of the following apply for NMOSD acute optic neuritis:

PLEX for NMOSD optic neuritis: Acute optic neuritis in NMOSD/NMO used as second-line or adjunctive therapy after insufficient response to first-line treatment or when rapid escalation is clinically required; documented visual acuity deficit and objective baseline/post-treatment assessments planned; rationale for PLEX versus other rescue therapies documentedFailure of or contraindication to first-line therapies

Systematic review found inadequate evidence to determine efficacy for visual acuity recovery; available data are small and observational

Coverage considerations by indication

Coverage considerations and evidence-based conclusions for multiple indications summarized from the cited literature:

Myeloma cast nephropathy: Plasmapheresis as adjunct to chemotherapy may reduce dialysis dependence in some studies but has not shown benefit as standalone therapy; use should be adjunctive with documented chemotherapy plan

Gupta et al., 2010; Premuzic et al., 2018

NMOSD acute optic neuritis: PLEX used as second-line/adjunctive therapy shows inconclusive benefit for visual acuity recovery; evidence inadequate to determine efficacy

Naphattalung et al., 2023

Pediatric ABO-incompatible heart transplant: ABO-IA and ABO-PE produce similar survival and rejection outcomes; ABO-IA associated with lower transfusion volume and allows older recipients in selected cases

Issitt et al., 2021; Dipchand et al., 2010

ANCA-associated vasculitis (MPA/GPA) — evidence-based summary

ANCA-associated vasculitis (MPA/GPA) — evidence-based summary:

Evidence summary: Randomized trials found no association of plasma exchange with mortality, complete remission, or adverse events compared with no plasma exchange; however, plasma exchange was associated with reduced incidence of end-stage renal disease at three months in some trials—interpret with caution and document renal-specific indications if used

No RCT evidence for EGPA; further research needed

Sepsis with multiorgan dysfunction — adjunct TPE

Sepsis with multiorgan dysfunction — adjunct TPE evidence summary:

Evidence summary: Systematic review/meta-analysis indicates adjunct TPE with donor plasma was associated with reduced short-term mortality (RR 0.59, 95% CI 0.47–0.74) versus standard therapy alone; however, trials were small and heterogeneous and larger RCTs are needed before routine adoption

Interpret cautiously due to trial size and heterogeneity

Alzheimer disease — plasma exchange with albumin (PE-Alb) considerations

Alzheimer disease (mild or moderate) — evidence summary:

Evidence summary: Insufficient quality evidence to support apheresis for Alzheimer's disease; a randomized trial (AMBAR-related analyses) showed biomarker and some clinical associations but findings require replication in larger studies

Further research required

FSGS — apheresis evidence and coverage stance

FSGS — apheresis evidence summary:

Evidence summary: Insufficient quality evidence to support therapeutic plasma exchange or LDL apheresis for steroid-resistant focal segmental glomerulosclerosis; small studies suggest possible delay in progression to ESRD but data are limited and not generalizable

Studies small and mainly conducted in Japan; further long-term studies needed

Idiopathic inflammatory myopathies — TPE

Idiopathic inflammatory myopathies — TPE evidence summary:

Evidence summary: Evidence is insufficient; small retrospective series suggest possible benefit in refractory necrotizing autoimmune myopathy (HMGCR or SRP antibodies) and some PM/DM-ILD cases refractory to conventional therapy, but studies are limited by design and size

Risk factors such as subcutaneous/mediastinal emphysema and high ferritin may predict poor response in PM/DM-ILD

ITP — TPE

Immune thrombocytopenia (ITP) — TPE evidence summary:

Evidence summary: Insufficient quality evidence to support routine use of apheresis for ITP; small retrospective series report partial and complete responses in refractory chronic ITP but lack control groups

Patients often had prior therapies including corticosteroids and IVIG

Pemphigus vulgaris — plasma exchange

Pemphigus vulgaris — plasmapheresis evidence summary:

Evidence summary: Insufficient evidence to support apheresis for pemphigus vulgaris; plasma exchange was evaluated in one small trial with inconclusive effects on remission or mortality

RCTs insufficiently powered

PTP — TPE

Post-transfusion purpura (PTP) — TPE evidence summary:

Evidence summary: Evidence limited to case reports/series; isolated reports suggest TPE may contribute to platelet recovery after IVIG/steroids but controlled data are lacking

Prospective controlled trials needed

Stiff-person syndrome — TPE

Stiff-person syndrome (anti-GAD65) — TPE evidence summary:

Evidence summary: Small retrospective series report symptomatic benefit in some anti-GAD65 SPS patients refractory to conventional treatments; TPE used acutely and as chronic maintenance in some cases but evidence is limited and uncontrolled

Single-center retrospective data

Sydenham's chorea — IVIG / plasma exchange

Sydenham's chorea — IVIG / plasma exchange evidence summary:

Evidence summary: Small RCT (n=18) suggested more rapid improvement with IVIG and plasma exchange versus prednisone, but between-group differences were not statistically significant; larger trials required

Insufficient evidence for broad recommendation

TEN / SJS — plasmapheresis

Toxic epidermal necrolysis (TEN) / SJS — plasmapheresis evidence summary:

Evidence summary: Evidence is insufficient and heterogeneous; some single-center observational studies report faster recovery and lower mortality with plasmapheresis, but pooled analyses show limited beneficial findings compared to other systemic immunomodulating therapies; use should be individualized and considered experimental outside controlled settings

Most studies are retrospective or observational

Kawasaki disease — plasma exchange for IVIG-refractory cases

Kawasaki disease — plasma exchange for IVIG-refractory cases:

Evidence summary: Retrospective data suggest plasma exchange reduced coronary artery lesion development in IVIG-refractory high-risk children compared with a third IVIG course (17.3% vs 40.7%); study limitations require cautious interpretation and RCT data are needed

Different IVIG regimens used; retrospective design

Specialty-guideline coverage groupings

Coverage and clinical stance summarized from specialty society guidelines and authoritative sources:

Sickle cell disease - exchange/transfusion: Apheresis (RBC exchange/automated exchange) is recommended or an option for acute stroke, severe acute chest syndrome, and as prophylaxis for primary/secondary stroke with goals of HbS <30% and hemoglobin >9.0 g/dL for secondary prevention; individualized approach per ASH and ASFA guidanceHbS <30%; Hgb >9.0 g/dL

ASH guideline recommendations

APL/leukapheresis: Leukapheresis is not routinely recommended in acute promyelocytic leukemia but may be considered in life‑threatening leukostasis unresponsive to other measuresClinical leukostasis refractory to other measures

NCCN guidance

Hyperviscosity/multiple myeloma: Plasmapheresis is indicated as adjunctive therapy for symptomatic hyperviscosity in multiple myeloma

General coverage determination

General coverage determination:

General coverage rule: Therapeutic apheresis (including plasma exchange/plasmapheresis, photopheresis, immunoadsorption, and related modalities) is covered only for conditions explicitly listed as proven and medically necessary in this policy; any indication not listed is considered unproven and not medically necessary

Medical records documentation supporting criteria, timing, and modality may be required

Therapeutic apheresis, as defined in this policy, is an umbrella term for procedures that remove, filter, or otherwise treat blood or plasma components and does not include stem cell collection or harvesting for bone marrow/stem cell transplantation.

Systematic reviews and single-center cohort data did not demonstrate that routine prophylactic plasmapheresis reduces recurrence of focal segmental glomerulosclerosis (FSGS) after kidney transplantation. A pooled analysis found no significant difference in recurrence with rituximab ± plasmapheresis versus standard care (RR 0.82, 95% CI 0.47–1.45) and plasmapheresis alone showed no significant reduction in recurrence (RR 0.85, 95% CI 0.60–1.21). A small retrospective series similarly found no benefit from prophylactic plasmapheresis in deceased-donor recipients and recommended against routine prophylactic use absent randomized data.

A systematic review of extracorporeal removal of serum free light chains in multiple myeloma with acute renal injury did not show a benefit for plasmapheresis when used as a standalone therapy independent of appropriate anti‑myeloma chemotherapy; evidence supports its role only as an adjunct in selected cases.

For many listed indications (for example Alzheimer's disease, FSGS, idiopathic inflammatory myopathies, ITP, pemphigus vulgaris, PTP, stiff‑person syndrome, Sydenham's chorea, TEN/SJS, and Kawasaki disease), the available studies are limited in size, observational in design, or heterogeneous in methods and outcomes. These limitations result in predominantly insufficient or low‑certainty evidence and preclude broad, coverage‑positive recommendations for numerous conditions.

Evidence for plasma exchange in Kawasaki disease is limited and primarily retrospective. One retrospective study reported fewer coronary artery lesions after plasma exchange compared with a third IVIG course in IVIG‑refractory, high‑risk children, but methodological limits and differing IVIG regimens temper confidence. ASFA and practice guideline summaries note insufficient high‑quality evidence and categorize some pediatric vasculitis indications as not well supported.

The policy language has been revised to clarify that therapeutic apheresis, including plasma exchange or photopheresis, is considered unproven and not medically necessary for any conditions or diagnoses not specifically listed as proven and medically necessary in this policy. This replaces prior phrasing that limited the unproven/not medically necessary designation to a finite listed set of conditions.

Consistent with the policy's scope, therapeutic apheresis (including plasmapheresis, photopheresis, immunoadsorption, LDL apheresis, and related procedures) is considered unproven and not medically necessary when used to treat or manage conditions that are not explicitly listed in the policy as proven and medically necessary; many individual indications lack sufficient quality evidence to support routine coverage.

Pooled observational data did not show a reduced risk of recurrent FSGS after kidney transplantation with the use of rituximab with or without plasmapheresis, or with plasmapheresis alone; therefore, use of rituximab ± plasmapheresis for prophylaxis of recurrent FSGS post‑transplant is not supported as effective for recurrence prevention in the available evidence.

Plasmapheresis achieves more rapid reductions in serum triglyceride levels in hypertriglyceridemia‑induced acute pancreatitis compared with conventional therapy, but systematic reviews report no clear improvement in clinical prognosis and some pooled observational data suggest higher in‑hospital mortality in plasmapheresis groups; therefore plasmapheresis solely to lower triglycerides without evidence that this change will improve outcomes is not clearly supported.

Systematic review evidence for plasma exchange (PLEX) in acute optic neuritis due to neuromyelitis optica/NMOSD is limited and inconclusive. Small observational studies showed variable timing and outcomes, and pooled analyses did not demonstrate statistically significant visual‑acuity benefit at evaluated time points, yielding insufficient evidence to confirm efficacy for improving visual acuity.

The following uses have insufficient quality evidence to support routine apheresis: Alzheimer's disease, focal segmental glomerulosclerosis (FSGS), idiopathic inflammatory myopathies, immune thrombocytopenia (ITP), pemphigus vulgaris, post‑transfusion purpura (PTP), stiff‑person syndrome, Sydenham's chorea, and toxic epidermal necrolysis (TEN) / Stevens‑Johnson syndrome (SJS). Available data are mainly case series, small retrospective cohorts, or underpowered trials; therefore requests for these indications generally require detailed individualized justification and are at higher risk for denial.

Given the limitations of available studies (retrospective design, heterogeneous regimens, and limited sample sizes), apheresis for Kawasaki disease is generally not considered medically necessary based on current evidence and may be denied absent compelling case‑specific data or trial enrollment.

The policy wording that previously confined the 'unproven and not medically necessary' designation to a specific list of conditions was replaced; the current policy explicitly treats any indication not listed as proven and medically necessary as unproven and not medically necessary, and documents that medical‑record evidence may be requested to evaluate clinical justification.

Permitted Procedures and Treatment Regimens

Procedure	Indication	Coverage status
Photopheresis / Extracorporeal photopheresis (ECP)	Cutaneous T-cell lymphoma (including erythrodermic mycosis fungoides and Sézary syndrome)	Covered
Therapeutic plasma exchange (plasmapheresis)	Various indications listed in policy (see covered indications) including hyperviscosity, familial hypercholesterolemia (TPE in some cases)	Covered for listed indications
Immunoadsorption / selective adsorption procedures	Idiopathic dilated cardiomyopathy via immunoadsorption; other immune-mediated indications per policy	Covered for listed indications
Leukapheresis (cell removal)	Acute promyelocytic leukemia with life‑threatening leukostasis (consider with caution; not routine)	Conditional / Not routinely recommended

Procedure	Clinical context / required elements	Coverage status
Therapeutic plasma exchange (plasmapheresis)	Multiple myeloma with acute kidney injury due to light‑chain (cast) nephropathy; used as adjunct to appropriate chemotherapy (e.g., bortezomib‑containing regimens); planned multiple sessions (often ≥3) documented	Covered (second‑line/adjunct)

Device / Procedure	Indication	Coverage status
Extracorporeal photopheresis (Therakos CELLEX / UVAR XTS systems)	Palliative treatment of skin manifestations from cutaneous T‑cell lymphoma unresponsive to other treatments (FDA‑approved indication)	Covered

Procedure	Clinical context / policy note	Coverage status
Leukapheresis	Not recommended routinely in acute promyelocytic leukemia (APL); may be considered with caution for life‑threatening leukostasis not responsive to other modalities	Conditional / Use with caution

Procedure	Indication	Coverage status
Plasmapheresis / Therapeutic plasma exchange	Adjunctive therapy for symptomatic hyperviscosity (e.g., multiple myeloma with symptomatic hyperviscosity) to rapidly reduce viscosity and relieve symptoms	Covered with criteria

Line of Therapy and Sequencing Expectations

second-line

Second-line/adjunctive therapy: Indication is designated as second-line or adjunctive: plasmapheresis is used after or in conjunction with prior/standard therapies (e.g., cryoglobulinemia, recurrent FSGS in transplant, heterozygous familial hypercholesterolemia, chronic graft-versus-host disease, neuromyelitis optica relapses, myeloma cast nephropathy adjunct to chemotherapy)

Document prior therapies and rationale

second-line

Second-line/adjunct: Plasmapheresis for myeloma cast nephropathy is considered second-line/adjunctive and should be used in combination with appropriate chemotherapy; not indicated as replacement for systemic anti-myeloma therapy

Systematic review did not show benefit independent of chemotherapy

Biomarker and Laboratory Requirements

serum free light chains (sFLC) — elevated sFLCs consistent with cast nephropathy

Required biomarkerElevated serum free light chains (sFLC) consistent with cast nephropathy

Clinical contextAcute kidney injury in multiple myeloma where rapid FLC reduction is sought as adjunct to chemotherapy

Treatment intentAdjunctive plasmapheresis (multiple sessions, often ≥3) combined with appropriate anti-myeloma chemotherapy

Procedure Codes and Coding Definitions

Applicable CPT codes (reference)CPT

0342T	Therapeutic apheresis with selective HDL delipidation and plasma reinfusion.
36511	Therapeutic apheresis; for white blood cells.
36512	Therapeutic apheresis; for red blood cells.
36513	Therapeutic apheresis; for platelets.
36514	Therapeutic apheresis; for plasma pheresis.
36516	Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion.
36522	Photopheresis, extracorporeal

Referenced procedures (no codes listed)mixed

not specified in this segment

No explicit CPT/HCPCS/ICD-10 codes are listed in these chunks.

High-Volume Plasma Exchange definition — exchange volume and rate

Exchange volumeDefined as exchange of 15% of ideal body weight (approximately 8–12 L)

Removal ratePlasma removed at a rate of 1–2 L per hour

ReplacementReplaced with plasma in equivalent volume

Hct threshold — baseline Hct ≥ 30% associated with increased adverse events during chronic RCE

Hct thresholdBaseline hematocrit (Hct) ≥ 30% is associated with increased adverse events during chronic red cell exchange (RCE)

Observed risksHigher total and symptomatic adverse event rates reported in patients with Hct ≥ 30%

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Codes referenced; prior authorization expectation

The following items summarize required provider actions for prior authorization, documentation, and risks related to therapeutic apheresis requests. Prior authorization is required for many apheresis services; submit clinical documentation that confirms the indication, planned modality and number/frequency of sessions, concurrent therapies (for example chemotherapy for myeloma cast nephropathy), and any intent for chronic therapy (e.g., chronic red cell exchange). Benefits and coverage decisions remain subject to the member's federal, state, and contractual benefit requirements.

Codes referenced for provider/billing reference include: 0342T; 36511; 36512; 36513; 36514; 36516; 36522. Listing is for reference only and does not guarantee coverage or payment.
UnitedHealthcare uses InterQual as the primary source for medical/surgical criteria; check contractual/state/federal requirements for coverage differences.

Prior Authorization

Prior authorization: indication, session plan, and concurrent therapy required

When requesting prior authorization, document the clinical indication, the planned session regimen (number, frequency, duration), the specific apheresis modality (e.g., TPE, red cell exchange, photopheresis, LDL apheresis, immunoadsorption), any concurrent or adjunctive therapies (for example chemotherapy when used for myeloma cast nephropathy), and timing relative to other procedures (for example transplantation occurring within days of desensitization). Authorization for guideline-level indications (for example LDL apheresis for homozygous familial hypercholesterolemia, desensitization protocols for transplantation) should reference specialty guideline support and demonstrate that guideline-based sequencing (drug therapy tried prior to apheresis where recommended) has been followed.

Terms and Definitions

Therapeutic apheresis comprises a group of procedures in which a patient's blood is collected, selected components (for example plasma, red cells, platelets, leukocytes) are removed or treated extracorporeally, and the remaining blood components are returned to the patient. Modalities include plasma exchange (plasmapheresis), immunoadsorption, extracorporeal photopheresis, LDL apheresis, erythrocytapheresis, leukapheresis, and other filtration‑ or adsorption‑based techniques. Procedures are typically outpatient, require several hours, and some indications call for multiple or daily sessions.

Therapeutic apheresis — umbrella term and general definition

Umbrella termTherapeutic apheresis: procedures in which blood is collected, selected components are removed, and remaining components are reinfused (aka pheresis)

Included modalitiesExamples include plasmapheresis, photopheresis, immunoadsorption, LDL apheresis, erythrocytapheresis, leukocytapheresis

Typical setting/durationUsually outpatient procedures that may require several hours; some indications may require daily exchanges for at least one week

High-Volume Plasma Exchange (HVP) — definition and parameters

Evidence Summaries and Key Metrics

211largest desensitization cohort (live‑donor renal transplant)

50hoFH pediatric registry cases for lipoprotein apheresis

1080HTG‑AP observational study patients pooled

395DCM patients in IA meta‑analysis

Document Revision History

2026-03-01policy_revisionLatest

Replaced prior wording limiting 'unproven and not medically necessary' to listed conditions with broader language stating therapeutic apheresis (including plasma exchange and photopheresis) is unproven and not medically necessary for any conditions not listed as proven and medically necessary; added detailed medical records documentation requirements and updated supporting sections (Clinical Evidence, FDA, References).

OpenPayer

Apheresis (for Kentucky Only)