Apheresis (for North Carolina Only) / Medical Policy
UnitedHealthcare medical policy CSNCT0136.04 (effective 2025-12-01) governing coverage of therapeutic apheresis procedures for members in North Carolina, listing diagnoses/conditions where therapeutic apheresis is medically necessary, conditions considered unproven/not medically necessary, documentation requirements, applicable procedure codes, and descriptions of apheresis services. This is part 1 of 4 of the policy document.
Replaced language indicating therapeutic apheresis was unproven and not medically necessary for treating or managing the [listed] conditions/diagnoses with language stating therapeutic apheresis is unproven and not medically necessary for treating or managing any other conditions/diagnoses not listed in the policy as proven and medically necessary.
Removed reference link to the guidelines titled Medical Records Documentation Used for Reviews.
Added language specifying documentation elements required in the patient's medical record to support medical necessity.
Added notation that CPT/HCPCS codes 0342T and S2120 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.
Updated Clinical Evidence, FDA, and References sections to reflect the most current information.