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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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PacifiCare Medical Management Guidelines Manual


PacifiCare’s medical management guidelines represent the recommendation of the

PacifiCare Medical Management Guideline (MMG) committee. They are based on the

MMG committee's review of the available evidence as of the date of the medical

management guideline. Medical management guidelines are subject to change based upon changes in state and federal laws and regulations, changes in scientific knowledge/technology, and evolving practice patterns.

Medical management guidelines contain clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. Medical management guidelines are developed using peer-reviewed medical literature, publications, reports, professional or governmental guidelines, and other authoritative medical sources that relate to medical treatment or service. Medical management guidelines are intended to support consistent, appropriate medical necessity determinations, but they do not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.

Refer to member specific Evidence of Coverage (EOC), Schedule of Benefits (SOB), or Certificate of Coverage (COC). If there is a discrepancy between a medical management guideline and the member’s EOC/SOB/COC, the member’s EOC/SOB/COC provision will govern.


Medical Management Guidelines:

• Apheresis

• Artificial Total Disc Replacement for the Spine

• Athletic Pubalgia Surgery

• Auditory Integration Training

• Autologous Chondrocyte Transplantation In The Knee

• Balloon Sinuplasty

• Bariatric Surgery

• Bone Healing and Fusion Enhancement Products

• Breast Imaging for Screening and Diagnosing Cancer

• Cardiac Computed Tomography (CT), Coronary Artery Calcium Scoring and Cardiac CT Angiography

• Cardiovascular Disease Risk Tests

• Cervical Cancer Screening

• Chelation Therapy

• Chemosensitivity and Chemoresistance Assays in Cancer

• Cochlear Implants

• Cognitive Rehabilitation

• Computed Tomographic Colonography

• Computed Tomography (CT) Angiography of the Head

• Computerized Dynamic Posturography

• Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes

• Core Decompression For Avascular Necrosis

• Corneal Hysteresis Measurement

• Cryopreservation of Reproductive Tissue

• Cytological Examination of Breast Fluids for Cancer Screening

• Deep Brain Stimulation

• Dermatoscopy and Surveillance Photography for Detection of Melanoma

• Digital Infrared Thermal Imaging

• Discogenic Pain, Treatment

• Dysfunctional Uterine Bleeding and Uterine Fibroids

• Electrical and Ultrasound Bone Growth Stimulators

• Electrical Bioimpedance for Cardiac Output Measurement

• Electrical Stimulation and Electromagnetic Therapy for Wounds

• Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

• Endoscopic Therapies For Gastroesophageal Reflux Disease (GERD)

• Epidural Steroid and Facet Injections for Spinal Pain

• Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography

• Excimer Laser For Ophthalmic Procedures

• Extracorporeal Shock Wave Therapy (ESWT) for Orthopedic Indications

• Extraoperative Neurophysiologic Testing

• Fecal DNA Testing

• Femoroacetabular Impingement Syndrome

• Fetal Tissue Transplantation for Treatment of Parkinson's Disease

• Gait Analysis

• Gastric Stasis, Diagnosis and Treatment with Electrical Systems

• Genetic Testing

• Genetic Testing for Breast Cancer: BRCA1, BRCA2 and BRAC

• High End DME

• High Frequency Chest Wall Compression Devices

• Home Hemodialysis

• Human Immunodeficiency Virus (HIV) Tropism Testing

• Hyperbaric Oxygen Therapy

• Hyperthermic Chemotherapy

• Imaging for Screening Asymptomatic Persons

• Implantable Beta-Emitting Microspheres For Treatment Of Malignant Tumors

• In Utero Fetal Surgery

• Infertility Diagnosis and Treatment

• Intensity-Modulated Radiation Therapy

• Intensity-Modulated Radiation Therapy for Breast Cancer

• Intensive Behavioral Therapy for the Treatment of Autism Spectrum Disorders

• Intermittent Intravenous Insulin Therapy

• Intraoperative Neurophysiologic Monitoring

• Intraoral Appliances and Implanted Devices for Treatment of Obstructive Sleep Apnea

• Intrastromal Corneal Ring Segments For Vision Correction and Keratoconus

• KRAS Mutation Analysis in Metastatic Colorectal Cancer

• Light and Laser Therapy for Skin Conditions

• Lithotripsy for Salivary Stones

• Lyme Disease

• Magnetic Resonance Spectroscopy (MRS) for Evaluation of Neurological Disorders

• Magnetoencephalography And Magnetic Source Imaging For Specific Neurological Applications

• Manipulation Under Anesthesia

• Maxillomandibular Advancement Surgery for Treatment of Obstructive Sleep Apnea

• Mechanical Stretching and Continuous Passive Motion Devices

• Metacarpophalangeal and Proximal Interphalangeal Joint Implant

• Minimally Invasive Lumbar Spinal Fusion

• Neuropsychological Testing

• Neutron Beam Radiation Therapy For Cancer

• Nitric Oxide Breath Test and Exhaled Breath Condensate pH for Asthma


Medical Management Guidelines:

• Occipital Neuralgia and Cervicogenic Headache

• Oral-Pharyngeal Tissue Reduction for Treatment of Obstructive Sleep Apnea

• Orthognathic Surgery

• Orthoptic and Vision Therapy

• Passive Rehabilitation Therapy for Mandibular Hypomobility

• Photon Absorptiometry and Collagen Crosslinks

• Plagiocephaly and Craniosynostosis Treatment

• Platelet Derived Growth Factors for Treatment of Wounds

• Plethysmography

• Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders

• Positron Emission Tomography (PET) and Combined PET Computed Tomography (CT) scans

• Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain

• Preterm Labor: Identification and Treatment

• Prolotherapy for Musculoskeletal Indications

• Proton Beam Radiation Therapy

• Radiofrequency Ablation for the Treatment of Orthopaedic and Spinal Pain

• Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence

• Real-Time Cardiac Surveillance

• Repair of Pectus Deformities

• Robotic-Assisted Surgery

• Semi-Implantable Electromagnetic and Bone-Anchored Hearing Aids

• Sensory Integration and Coordination Therapy

• Single Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI)

• Sodium Hyaluronate for the Treatment of Arthritis

• Spinal Stabilization and Decompression Devices

• Spinal Unloading Treatment for Low Back Pain

• Standing Systems

• Stereotactic Radiosurgery

• Sural Nerve Graft to Restore Erectile Function During Radical Prostatectomy

• Surgical and Minimally Invasive Treatment for Varicose Veins of the Leg

• Temporomandibular Joint Disorders

• Testing for the Diagnosis and Management of Inflammatory Bowel Disease

• Thermal Shrinkage Therapy for Joint Capsules, Ligaments and Tendons

• Topical Oxygen Therapy for Wounds

• Total Artificial Heart

• Total Hip Resurfacing Arthroplasty

• Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting

• Transpupillary Thermotherapy for Macular Degeneration and Choroidal Tumors

• Transthoracic Echocardiography

• Transtympanic Micropressure

• Ultrasonography For The Diagnosis And Management Of Spinal Pain And Radiculopathies

• Umbilical Cord Blood Harvesting and Storage for Future Use

• Unicondylar Spacer Devices For Treatment Of Pain Or Disability

• Vagus Nerve Stimulation

• Virtual Upper Gastrointestinal Endoscopy

• Viscocanalostomy and Canaloplasty for the Treatment of Glaucoma

• Warming Therapy and Ultrasound Therapy for Wounds

• Wireless Capsule Endoscopy

Clinical Practice Guidelines:

• Acute Myocardial Infarction

• Attention Deficit Hyperactivity Disorder

• Asthma

• Bipolar Disorder

• Chronic Stable Angina

• Depression

• Diabetes

• Heart Failure

• Hyperbilirubinemia

• Hypertension

• NCCN: Drugs and Biologics Compendium

• Preventive Health Recommendations

• Spinal Stenosis Medical Management Guideline TITLE: Apheresis Authorized By: Medical Management Guideline Committee

Adoption Date: 06/29/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.

This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.

Member benefit coverage and limitations may vary based on the member’s benefit plan.


This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supersede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

–  –  –

Description After evaluating relevant benefit document language (exclusions or limitations), refer to Coverage sections of this document to determine coverage.

This policy describes the use of apheresis, which separates cells from plasma, and, in some cases, removes certain blood cells or components from the blood. This process may be useful in treating some diseases.

Apheresis - Commercial Medical Management Guideline

Coverage All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.

Coverage Rationale

Therapeutic apheresis or plasmapheresis is proven for the following diagnoses:

- ABO incompatible marrow transplant (red cell removal) (recipient: plasma exchange)

- Acute Guillain-Barre syndrome (plasma exchange)

- AIDS-related idiopathic thrombocytopenic purpura that is life-threatening (plasma exchange)*

- Bullous pemphigoid (plasma exchange)

- Coagulation factor inhibitors (plasma exchange)

- Chronic inflammatory demyelinating polyneuropathy (plasma exchange)

- Cryoglobulinemia (and other hyperviscosity syndromes including multiple myeloma, Waldenstrom's macroglobulinemia) (plasma exchange)

- Cutaneous lymphoma (photopheresis)

- Eaton-Lambert myasthenic syndrome (plasma exchange)

- Erythrocytosis/polycythemia vera (phlebotomy)

- Familial hypercholesterolemia (selective adsorption)**

- Goodpasture's syndrome (plasma exchange)

- Hemolytic uremic syndrome (plasma exchange)

- HIV related syndromes (plasma exchange)

- hyperviscosity

- polyneuropathy

- thrombotic thrombocytopenic purpura

- Leukocytosis and thrombocytosis (cytapheresis)

- Myasthenia gravis (plasma exchange)

- Myeloma and paraproteinemias (plasma exchange)

- Pemphigus vulgaris (plasma exchange)

- Poisonings (plasma exchange)

- Porphyria (phlebotomy)

- Post-transfusion purpura (plasma exchange)

- Primary/hereditary hemochromatosis (phlebotomy)

- Rapidly progressive nephritis (without anti-GBM) (plasma exchange)

- Raynaud's disease (plasma exchange)

- Refsum's disease (phytanic acid) (plasma exchange)

- Rheumatoid arthritis (immunoadsorption)

- Sickle cell diseases (red cell exchange)

- Systemic lupus erythematosis (plasma exchange)

- Systemic vasculitis (plasma exchange)

- Thrombotic thrombocytopenic purpura (plasma exchange) The above diagnoses and specific apheresis techniques are clinically indicated as an adjunct, or supportive to more definitive treatment.

*Clinical indications for use of extracorporeal immunoadsorption with protein A for treatment of life-threatening AIDSrelated idiopathic thrombocytopenic purpura include:

1) platelet counts below 100,000/mm3, AND

2) steroid treatments have failed, AND

3) and splenectomy has failed.

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