00113
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Renal transplant recipients who are ABO compatible who are experiencing antibody mediated rejection (AMR) or require desensitization (living donor)
- Wilsonâs disease - fulminant
- Renal transplant recipients who are ABO incompatible and require desensitization (living donor)
- Plasmapheresis or plasma exchange is consideredmedically necessaryfor any of the following conditions listed in alphabetical order below:Acute inflammatory demyelinating polyradiculoneuropathy / Guillain-Barre syndromeAnti-glomerular basement membrane disease (Goodpasture's syndrome) when the individual is dialysis-independent or there is evidence of diffuse alveolar hemorrhage (DAH)Atypical hemolytic uremic syndrome (aHUS) with Factor H autoantibodies or complement gene mutationAutoimmune hemol [...]
- Acute inflammatory demyelinating polyradiculoneuropathy / Guillain-Barre syndrome
- Anti-glomerular basement membrane disease (Goodpasture's syndrome) when the individual is dialysis-independent or there is evidence of diffuse alveolar hemorrhage (DAH)
1 Active Policy
ANTHEM-CG-MED-68 — CG-MED-68 Therapeutic Apheresis
Related Codes
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