M EDICAL P OLICY
P OLICY T ITLE
P OLICY N UMBER
Original Issue Date (Created):
P HLEBOTOMY
MP-1.059
July 1, 2002
December 21, 2010 Most Recent Review Date
(Revised):
Effective Date: August 31, 2011- RETIRED
I.
P OLICY
A therapeutic phlebotomy may be considered medically necessary for the following conditions:

Hemochromatosis

Porphyria cutanea tarda

Polycythemia vera

Polycythemia, secondary to:

A-V fistula

Cor pulmonale

Cyanotic heart disease.
II.
P RODUCT V ARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] Capital Cares 4 Kids [N] Indemnity
[N] PPO
[N] HMO
[N] SeniorBlue HMO
[N] SpecialCare
[N] POS
[N] FEP PPO
[N] SeniorBlue PPO
III.
D ESCRIPTION /B ACKGROUND
A therapeutic phlebotomy is the incision into a vein for the letting of blood. Phlebotomy is used in certain medical conditions to reduce blood viscosity or to reduce the amount of circulating blood. Phlebotomy usually involves removal of a full unit of blood from the patient, approximately five hundred (500) mls. The frequency of additional phlebotomy is dependent on the patient's medical condition and associated lab values.
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IV.
D EFINITIONS
MP-1.059
H EMOCHROMATOSIS is a genetic disease marked by excessive absorption and accumulation of iron into the body.
P OLYCYTHEMIA VERA is a chronic, life-shortening disease of the bone marrow, which results in overproduction of white blood cells, red blood cells, and platelets.
P ORPHYRIA CUTANEA TARDA is a condition in which a patient develops liver disease and rashes on sun-exposed parts of the body.
V.
B ENEFIT V ARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit under the member's contract.
Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member’s benefit information or contact Capital for benefit information.
VI.
D ISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member’s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law.
VII.
R EFERENCES
Adams PC, Barton JC. Haemochromatosis. Lancet. 2007 Dec 1;370(9602):1855-60.
Beutler, E. Iron storage disease: facts, fiction, and progress. Blood Cells Mol Dis 2007
May 30.
Finazzi G, Barbui T. Expertise-based management in essential thrombocythemia and polycythemia vera. Cancer J. 2007 Nov-Dec;13(6):372-6.
Mosby's Medical, Nursing, & Allied Health, 6 th
edition.
Sassa S. Porphyria cutanea tarda, hepatoerythropoietic porphyria, and toxic porphyri a
In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated June
30, 2009. [Website]: www.uptodate.com . Accessed August 31, 2010.
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Schrier S, Bacon B. Treatment of hereditary hemochromatosis. In: UpToDate Online
Journal [serial online]. Waltham, MA: UpToDate; updated October 13, 2009.
[Website] : www.uptodate.com Accessed August 31, 2010.
Taber's Cyclopedic Medical Dictionary, 20 th edition.
Teffero A.
Diagnostic approach to the patient with polycythemia In: UpToDate Online
Journal [serial online]. Waltham, MA: UpToDate; updated February 2, 2007.
[Website]: www.uptodate.com Accessed August 31, 2010.
VIII.
C ODING I NFORMATION
Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.
Covered when medically necessary:
CPT
Codes ®
99195
Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.
ICD-9-CM
Diagnosis
Code*
238.4
Description
NEOPLASM OF UNCERTAIN BEHAVIOR OF POLYCYTHEMIA VERA
275.01
275.02
275.03
HEREDITARY HEMOCHROMATOSIS
HEMOCHROMATOSIS DUE TO REPEATED RED BLOOD CELL TRANSFUSIONS
OTHER HEMOCHROMATOSIS
289.0 POLYCYTHEMIA, SECONDARY
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
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IX.
POLICY HISTORY
MP 1.059 CAC 6/29/04
MP-1.059
CAC 7/26/05
CAC 8/30/05
CAC 7/25/06
CAC 7/31/07
CAC 7/29/08
CAC 7/28/09 Consensus Review
CAC 11/30/10 Consensus review
Policy approved for retirement effective 8/31/2011.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
Company ® and Keystone Health Plan ® Central. Independent licensees of the Blue Cross and Blue Shield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
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