Therapeutic Apheresis for Familial Hypercholesterolemia

Noridian (per NCD 110.14 MAC discretion) covers plasma therapeutic apheresis for familial hypercholesterolemia refractory to appropriate lifestyle changes and maximal statin therapy (with or without ezetimibe) in functional homozygotes with LDL >500 mg/dL; functional heterozygotes without CVD with LDL >300 mg/dL; functional heterozygotes with CVD with LDL >200 mg/dL; and for FH in pregnancy when usual therapy is inadequate. All claims are subject to pre- or post-pay review and must have dated, signed medical-record documentation of medical necessity, prior pharmacologic agents used, lifestyle changes, and specific findings if statin intolerance is alleged (MLN MM4250 does not restrict this use).