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Phlebotomy, Therapeutic

 

DESCRIPTION

Therapeutic phlebotomy commonly includes removal of whole blood from a patient to reduce red blood mass.

 

POLICY

Therapeutic phlebotomy will be covered for following diagnoses only:

  • Polycythemia vera
  • Hemochromatosis
  • Primary erythrocytosis
  • Porphyria cutanea tarda
  • Secondary erythrocytosis
  • Congenital polycythemia

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

10/1993: Approved by Medical Policy Advisory Committee (MPAC)

4/5/2001: Policy reviewed; Managed Care Requirements deleted

5/2/2002: Type of Service and Place of Service deleted

9/20/2002: Code Reference section updated

2/13/2004: Code Reference section reviewed, no changes

3/10/2006:  Coding updated.  CPT4/HCPCS 2006 revisions added to policy

12/31/2008: Policy reviewed, no changes

10/14/2010: Annual ICD-9 code update: 275.0 deleted/expanded to the fifth digit. Added 275.01 - 275.09 to the Covered Codes table.

03/10/2014: Policy reviewed; no changes.

 

SOURCE(S)

Laboratory Test Handbook

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

Code Number

Description

CPT-4

86960

Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit

99195

Phlebotomy, therapeutic (separate procedure)

ICD-9 Procedure

ICD-9 Diagnosis

238.4

Neoplasm of uncertain behavior of polycythemia vera 

275.01

Hereditary hemochromatosis

275.02  

Hemochromatosis due to repeated red blood cell transfusions

275.03 

Other hemochromatosis

275.09

Other disorders of iron metabolism

277.1

Disorders of porphyrin metabolism 

282.1 

Hereditary elliptocytosis 

285.0 

Sideroblastic anemia  

289.0 

Polycythemia, secondary  

289.6 

Familial polycythemia 

774.1

Perinatal jaundice from other excessive hemolysis

HCPCS

 

 

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