Does 36516 require prior authorization?

No, 36516 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 36516?

Medicare facility rate: $74.48. Non-facility rate: $2227.84. Work RVU: 1.52.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.52

Facility

$74.48

Non-Facility

$2227.84

Medical records for each visit must clearly document the medical necessity for apheresis, including which pharmacologic agents were tried and the details of lifestyle changes attempted.
If statin intolerance is claimed, the record must contain the actual findings and symptoms reported that support intolerance.
Clinical notes supporting the need for apheresis must be signed by the treating provider and dated for the date of service.
Claims may require submission of supporting documentation for pre- or post-payment review by Noridian or authorized Medicare auditors.

Plasma apheresis is covered for functional homozygotes with familial hypercholesterolemia who have an LDL cholesterol > 500 mg/dL and who remain refractory to appropriate lifestyle changes and maximal statin therapy with or without ezetimibe.
Plasma apheresis is covered for functional heterozygotes with familial hypercholesterolemia who have no known cardiovascular disease and an LDL cholesterol > 300 mg/dL despite appropriate lifestyle changes and maximal statin therapy with or without ezetimibe.
Plasma apheresis is covered for functional heterozygotes with familial hypercholesterolemia who have known cardiovascular disease and an LDL cholesterol > 200 mg/dL despite appropriate lifestyle changes and maximal statin therapy with or without ezetimibe.
Plasma apheresis is covered for familial hypercholesterolemia during pregnancy when the treating physician documents that usual therapy is inadequate to assure uteroplacental perfusion.
Plasma apheresis is covered for familial hypercholesterolemia that is resistant to appropriate lifestyle changes combined with maximal statin therapy, with or without ezetimibe.
Plasma apheresis is covered for functional homozygotes with LDL cholesterol greater than 500 mg/dL.

AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments

A54543 — Therapeutic Apheresis for Familial Hypercholesterolemia

A56289 — Billing and Coding: Therapeutic Apheresis for Familial Hypercholesterolemia

UHC-POL-apheresis — Apheresis

UMR-POL-UMR-apheresis — Apheresis

Ask Verity about documentation requirements, denial risks, or coverage in your state.