Medica Coverage Policy Policy Name: Therapeutic Apheresis (TA) - Plasmapheresis, Plasma Exchange Effective Date: 2/17/2020 Important Information - Please Read Before Using This Policy These services may or may not be covered by all Medica plans. Please refer to the member’s plan document for specific coverage information. If there is a difference between this general information and the member’s plan document, the member’s plan document will be used to determine coverage. With respect to Medicare and Minnesota Health Care Programs, this policy will apply unless those programs require different coverage. Members may contact Medica Customer Service at the phone number listed on their member identification card to discuss their benefits more specifically. Providers with questions about this Medica coverage policy may call the Medica Provider Service Center toll-free at 1-800-458-5512. Medica coverage policies are not medical advice. Members should consult with appropriate health care providers to obtain needed medical advice, care and treatment. Coverage Policy EXTRACORPOREAL COLUMN IMMUNOADSORPTION APHERESIS Therapeutic apheresis (TA) employing extracorporeal immunoadsorption (ECI) is COVERED for the following indications: 1. Acute inflammatory demyelinating polyneuropathy (Guillain-Barre syndrome, acute), primary treatment 2. Chronic inflammatory demyelinating polyradioculoneuropathy (CIDP) 3. Cryoglobulinemia, severe/sumptomatic 4. Dilated idiopathic cardiomyopathy, NYHA II-IV 5. Encephalitis associated with N-methyl D-aspartate receptor antibodies 6. Focal segmental glomerulosclerosis, recurrent in kidney transplant 7. Multiple sclerosis, acute attack/relapse 8. Myasthenia gravis, acute/short term and long term treatment 9. Neuromyelitis optica spectrum disorders, acute attack or relapse (Devic’s syndrome) 10. Renal transplantation, ABO compatible a. Antibody-mediated rejection or desensitization, or desensitization in living donor 11. Renal transplantation, ABO incompatible a. Antibody-mediated rejection b. Desensitizations, living donor 12. Voltage-gated potassium channel antibody related diseases TA employing ECI is investigative and unproven and therefore NOT COVERED for all other indications, including but not limited to treatment for 1. Coagulation factor inhibitors, alloantibody or autoantibody 2. Multiple sclerosis, chronic 3. Atopic (neuro) dermatitis (atopic eczema), recalcitrant 4. Immune thrombocytopenia, refractory 5. Paraneoplastic neurologic syndromes 5. Paraproteinemic demyelinating polyneuropathies, IgG/IgA/IgM 6. Pemphigus vulgaris, severe 7. Thrombotic microangiopathy, infection associated: Shiga toxin-mediated (STEC-HUS) Therapeutic Apheresis (TA) - Plasmapheresis, Plasma Exchange Page 1 of 7 Medica Coverage Policy 8. Renal transplantation, ABO compatible a. Desensitization, deceased donor There is insufficient reliable evidence in the form of high quality peer-reviewed medical literature to establish the efficacy or effects on health care outcomes. The investigative determination does not apply to HDE approved devices. HDE approved devices are covered for the following: 1. Excorim® Immunoadsorption System (H970004) for the treatment of individuals with hemophilia A and B who have Factor VIII or Factor IX inhibitor titers above 10 BU/ml. EXTRACORPOREAL LOW-DENSITY LIPOPROTEIN APHERESIS TA employing extracorporeal low-density lipoprotein apheresis is COVERED for the treatment of: 1. Familial hypercholesterolemia, refractory, either homozygous or heterozygous 2. Lipoprotein (a) hyperlipoproteinemia 3. Peripheral vascular disease 4. Phytanic acid storage disease (Refsum’s disease). TA employing extracorporeal low-density lipoprotein apheresis is investigative and unproven and therefore NOT COVERED for all other indications, including but not limited to: 1. Hypertriglyceridemic pancreatitis, severe, including prevention of relapse 2. Steroid-resistant focal segmental glomerulosclerosis in native kidney, recurrent in kidney transplant 3. Sudden sensorineural hearing loss There is insufficient reliable evidence in the form of high quality peer-reviewed medical literature to establish the efficacy or effects on health care outcomes. The investigative determination does not apply to FDA Humanitarian Device Exemption (HDE) approved devices for specific indications. The following HDE approved device is covered for the following: 1. LIPOSORBER® LA-15 System (H170002) for the treatment of adult and pediatric patients with nephrotic syndrome associated with primary focal segmental glomerulosclerosis, when standard treatment options, including corticosteroid and/or calcineurin inhibitors treatments, are unsuccessful or not well tolerated and the patient has a glomerular filtration rate (GFR) greater than or equal to 60 ml/min/1.73m2 or the patient is post renal transplantation. STANDARD PLASMAPHERESIS / PLASMA EXCHANGE NOTE: Clinical conditions have been listed by general disease groupings. Although it is recognized that disease grouping definitions are often fluid and overlapping, this format is intended to aid in application of the position statement. TA employing standard plasmapheresis/plasma exchange methodology is COVERED for the following indications: AUTOIMMUNE / RHEUMATIC 1. Hyperglobulinemias and macroglobulinemias producing hyperviscosity syndromes, including but not limited to multiple myeloma, cryoglobulinemia, and Waldenstrom’s macroglobulinemia 2. Systemic lupus erythematosus, severe complications (e.g., cerebritis, diffuse alveolar hemorrhage) 3. Catastrophic antiphospholipid syndrome (CAPS). HEMATOLOGIC 1. Autoimmune hemolytic anemia, severe cold agglutinin disease 2. Hyperviscosity in monoclonal gammopathies (e.g., treatment of symptoms; prophylaxis for rituximab) 3. Acquired thrombotic thrombocytopenic purpura (TTP), autoimmune. HEPATIC 1. Acute liver failure requiring high volume apheresis Therapeutic Apheresis (TA) - Plasmapheresis, Plasma Exchange Page 2 of 7 Medica Coverage Policy METABOLIC 1. Factor H autoantibodies, thrombotic microangiopathy, complement related 2. Familial hypercholesterolemia, homozygous with small blood volume 3. Overdose, venoms, and poisoning: mushroom poisoning 4. Refsum’s disease (phytanic acid storage disease) 5. Thrombotic microangiopathy: a. Complement-mediated: Factor H autoantibodies b. Drug-associated: Ticlopidine 6. Thyroid storm 7. Vasculitis: Hepatitis B virus-associated polyarteritis nodosa (HBC-PAN) 8. Voltage-gated potassium channel antibody related diseases 9. Wilson’s disease, fulminant hepatic failure with hemolysis. NEUROLOGICAL 1. Acute inflammatory demyelinating polyneuropathy (Guillain-Barre syndrome, acute), primary treatment 2. Multiple sclerosis, acute attack/relapse 3. Acute disseminated encephalomyelitis, steroid refractory 4. Multiple myeloma, severe/symptomatic cryoglobulinemia 5. Chronic inflammatory demyelinating polyradioculoneuropathy (CIDP) 6. Paraproteinemic demyelinating polyneuropathies (e.g., IgG/IgA/IgM) 7. Lambert-Eaton myasthenic syndrome 8. Myasthenia gravis, acute/short term and long term treatment 9. Neuromyelitis optica spectrum disorders, acute attack or relapse (Devic’s syndrome) 10. Pediatric autoimmune neuropsychiatric disorders associated with: a. Streptococcal infections (PANDAS), exacerbation 11. Steroid responsive encephalopathy associated with autoimmune thyroiditis (Hashimoto’s encephalopathy) 12. Encephalitis associated with N-methyl D-aspartate receptor antibodies. RENAL (other than transplant-related) 1. Anti-glomerular basement membrane disease (Goodpasture’s syndrome): a. When dialysis independent b. With diffuse alveolar hemorrhage (DAH). 2. ANCA-associated vasculitis a. When dialysis dependent or imminent b. With diffuse alveolar hemorrhage (DAH) 3. Myeloma cast nephropathy. TRANSPLANTATION 1. Cardiac transplantation, desensitization 2. Focal segmental glomerulosclerosis, recurrent, in transplanted kidney 3. Hematopoietic stem cell transplant (HSCT), major ABO incompatibility (ABOi) 4. Liver transplantation, ABO incompatible: live donor desensitization 5. Renal transplantation, ABO compatible: a. Antibody mediated rejection b. Living donor desensitization 6. Renal transplantation, ABO incompatible: a. Antibody mediated rejection b. Living donor desensitization. All other applications of TA employing standard plasmapheresis/plasma exchange are considered investigative and unproven and therefore NOT COVERED. There is insufficient reliable evidence in the form of high quality peer- reviewed medical literature to establish the efficacy or effects on health care outcomes. Examples of applications that are considered investigative include, but are not limited to: Therapeutic Apheresis (TA) - Plasmapheresis, Plasma Exchange Page 3 of 7 Medica Coverage Policy AUTOIMMUNE / RHEUMATIC 1. Dermatomyositis, polymyositis, or inclusion body myositis Inclusion body myositis 2. Neonatal lupus, cardiac 3. Pemphigus vulgaris, severe 4. Progressive systemic sclerosis (scleroderma) 5. Psoriasis, disseminated pustular 6. Rheumatoid arthritis, refractory 7. Toxic epidermal necrolysis, refractory HEMATOLOGIC 1. Hemophagocytic lymphocytosis (HLA); macrophage activating syndrome 2. Warm autoimmune hemolytic anemia, severe 3. Coagulation factor inhibitors, alloantibody or autoantibody 4. Red cell alloimmunization in pregnancy, gestational age less than 20 weeks 5. Thrombocytopenic purpura (TP), other than thrombotic TP (e.g., Henoch-Schonlein purpura, post-transfusion purpura, refractory immune thrombocytopenia). HEPATIC 1. Acute liver