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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:

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

None

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

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.

Laboratory Test Handbook

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

Covered Codes

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