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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 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.