Phlebotomy, Therapeutic

POLICY NUMBER

L.2.01.408

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.

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.

01/18/2023: Policy reviewed; no changes.

02/14/2024: Policy reviewed; no changes.

03/13/2025: 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

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