Billing and Coding: Therapeutic Apheresis for Familial Hypercholesterolemia

CGS covers plasma apheresis for familial hypercholesterolemia that is refractory to appropriate lifestyle changes and maximal statin therapy (± ezetimibe) in defined subgroups: functional homozygotes with LDL >500 mg/dL; functional heterozygotes without CVD and LDL >300 mg/dL; functional heterozygotes with CVD and LDL >200 mg/dL; and pregnant patients when usual therapy is judged inadequate to assure uteroplacental perfusion. Coverage is subject to Medicare contractor discretion, and all claims require detailed, provider-signed documentation of pharmacologic treatments, lifestyle modifications, and, when applicable, statin intolerance; claims are also subject to pre- or post-pay review.

"Plasma apheresis is covered for familial hypercholesterolemia that is resistant to appropriate lifestyle changes combined with maximal statin therapy, with or without ezetimibe."