CG-MED-68 Therapeutic Apheresis

Anthem CG-MED-68 addresses therapeutic apheresis, primarily plasmapheresis/plasma exchange (PLEX), and related procedures (low-density lipoprotein apheresis, selective HDL delipidation, cytapheresis, thrombocytapheresis). PLEX is medically necessary for specified conditions such as acute inflammatory demyelinating polyradiculoneuropathy/Guillain‑Barré syndrome, anti‑GBM (Goodpasture’s) disease when dialysis‑independent or with diffuse alveolar hemorrhage, atypical HUS with Factor H autoantibodies or complement gene mutation, severe cold agglutinin disease refractory to medical therapy, catastrophic antiphospholipid syndrome, and chronic inflammatory demyelinating polyneuropathy when all criteria are met (multi‑limb weakness/sensory deficits, demyelinating findings on nerve conduction studies, and exclusion of other polyneuropathies). PLEX and other apheresis modalities are not medically necessary when their criteria are not met or for all other indications; selective HDL delipidation is not medically necessary for any indication.