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Therapeutic phlebotomy commonly includes removal of whole blood from a patient to reduce red blood mass.
Therapeutic phlebotomy will be covered for following diagnoses only:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY10/1993: 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.
08/14/2015: Medical policy revised to add ICD-10 codes.
06/06/2016: Policy number L.2.01.408 added.
07/25/2016: Code Reference section updated to make the following correction: ICD-10 diagnosis code E58.1 should be D58.1.
Laboratory Test Handbook
CODE REFERENCEThis 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.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.