Plasmapheresis/Plasma Exchange/Therapeutic Apheresis (CPB 0285, reviewed 2026-04-16)

REQUIREMENTS: - Immediately (by April 30, 2026): Billing and claims review teams must obtain the complete list of CPT/HCPCS codes associated with plasmapheresis, plasma exchange, and therapeutic apheresis procedures from your billing system vendor or Aetna's coding reference, as the policy document references 'Applicable CPT / HCPCS / ICD-10 Codes' but does not list them in the provided text. - Update claim submission protocols in billing software to cross-reference all plasmapheresis-related claims against Aetna's 40+ approved medical necessity indications listed in this policy. - For any claim with a diagnosis code NOT explicitly listed in the 'Medical Necessity' section, flag for prior authorization review or denial with reference to the 'Experimental, Investigational, or Unproven' section. Specifically deny claims for conditions listed in the experimental category (e.g., Alzheimer's disease, ALS, anti-MAG neuropathy, bullous pemphigoid, chronic fatigue syndrome, etc.). - Providers must document the specific approved indication on all plasmapheresis claim submissions. Update encounter templates and orders to require providers to select from the approved indications list. - For hyperlipidemia-related claims: Verify triglyceride levels >1,000 mg/dL, lipase >3x upper limit of normal, and presence of hypocalcemia, lactic acidosis, or organ dysfunction before approving hypertriglyceridemia-induced acute pancreatitis claims. - For familial hypercholesterolemia (LDL apheresis): Verify documentation of 6-month trial of maximum tolerated drug therapy from at least 2 separate drug classes AND appropriate LDL levels (>500 mg/dL for homozygous; >300 mg/dL or >200 mg/dL with CAD history for heterozygous) before approval. - For Guillain-Barré syndrome: Ensure treatment is initiated within 2 weeks of symptom onset for ambulant patients or within 4 weeks for non-ambulant patients per American Academy of Neurology guidelines. - Consequences of inaction: Claims submitted for non-approved indications will be denied; claims lacking required medical necessity documentation will require rework; improper coding or missing diagnosis verification will result in payment denials and potential compliance issues.