S2120 — Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
- UnitedHealthcare may use third party tools (e.g., InterQual® criteria) to assist in administering benefits; additional documentation may be required per those tools or the Medical Records Documentation Used for Reviews protocol.
Key Coverage Criteria
- Multiple sclerosis, acute attack, or relapse, second line therapy
- Myasthenia gravis, acute
- Myeloma cast nephropathy, second line therapy
- Lipoprotein(a) hyperlipoproteinemia
- Acute inflammatory demyelinating polyneuropathy, primary treatment
- Acute liver failure [requiring high volume therapeutic plasma exchange (TPE-HV)]
4 Active Policies
ANTHEM-CG-MED-68 — CG-MED-68 Therapeutic Apheresis
UHC-POL-apheresis — Apheresis
UMR-POL-UMR-apheresis — Apheresis
SUREST-POL-SUREST-apheresis — Apheresis
Related Codes
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