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CMS Transmittals



National Coverage Determination
Procedure Code: 8XXXX
Extracorporeal Immunoadsorption Using Protein A Columns
CMS Policy Number: 20.5
Back to NCD List

Limitations:
MCS & B/MACs: Shall allow payment for ECI when billed with approved diagnoses. Use of Protein A columns are covered for the treatment of ITP and for the treatment of rheumatoid arthritis (RA) under certain conditions: Severe RA: active disease, > 5 swollen joints, >20 tender joints and morning stiffness > 60 minutes Failure of an adequate course of at least 3 Disease Modifying anti-Rheumatic Drugs(DMARDs). Failure does not include tolerance



To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

ICD-10Descriptor
D69.3 Immune thrombocytopenic purpura
M05.011 Felty's syndrome, right shoulder
M05.012 Felty's syndrome, left shoulder
M05.021 Felty's syndrome, right elbow
M05.022 Felty's syndrome, left elbow
M05.031 Felty's syndrome, right wrist
M05.032 Felty's syndrome, left wrist
M05.041 Felty's syndrome, right hand
M05.042 Felty's syndrome, left hand
M05.051 Felty's syndrome, right hip
M05.052 Felty's syndrome, left hip
M05.061 Felty's syndrome, right knee
M05.062 Felty's syndrome, left knee
M05.071 Felty's syndrome, right ankle and foot
M05.072 Felty's syndrome, left ankle and foot
M05.09 Felty's syndrome, multiple sites
M05.211 Rheumatoid vasculitis w rheumatoid arthritis of r shoulder
M05.212 Rheumatoid vasculitis w rheumatoid arthritis of l shoulder
M05.221 Rheumatoid vasculitis w rheumatoid arthritis of right elbow
M05.222 Rheumatoid vasculitis w rheumatoid arthritis of left elbow
M05.231 Rheumatoid vasculitis w rheumatoid arthritis of right wrist
M05.232 Rheumatoid vasculitis w rheumatoid arthritis of left wrist
M05.241 Rheumatoid vasculitis w rheumatoid arthritis of right hand
M05.242 Rheumatoid vasculitis with rheumatoid arthritis of left hand
M05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hip
M05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hip
M05.261 Rheumatoid vasculitis w rheumatoid arthritis of right knee
M05.262 Rheumatoid vasculitis with rheumatoid arthritis of left knee
M05.271 Rheumatoid vasculitis w rheumatoid arthritis of right ank/ft
M05.272 Rheumatoid vasculitis w rheumatoid arthritis of left ank/ft
M05.29 Rheumatoid vasculitis w rheumatoid arthritis mult site
M05.311 Rheu heart disease w rheumatoid arthritis of r shoulder
M05.312 Rheu heart disease w rheumatoid arthritis of l shoulder
M05.321 Rheumatoid heart disease w rheumatoid arthritis of r elbow
M05.322 Rheumatoid heart disease w rheumatoid arthritis of l elbow
M05.331 Rheumatoid heart disease w rheumatoid arthritis of r wrist
M05.332 Rheumatoid heart disease w rheumatoid arthritis of l wrist
M05.341 Rheu heart disease w rheumatoid arthritis of right hand
M05.342 Rheumatoid heart disease w rheumatoid arthritis of left hand
M05.351 Rheumatoid heart disease w rheumatoid arthritis of right hip
M05.352 Rheumatoid heart disease w rheumatoid arthritis of left hip
M05.361 Rheu heart disease w rheumatoid arthritis of right knee
M05.362 Rheumatoid heart disease w rheumatoid arthritis of left knee
M05.371 Rheu heart disease w rheumatoid arthritis of right ank/ft
M05.372 Rheu heart disease w rheumatoid arthritis of left ank/ft
M05.39 Rheumatoid heart disease w rheumatoid arthritis mult site
M05.411 Rheumatoid myopathy w rheumatoid arthritis of right shoulder
M05.412 Rheumatoid myopathy w rheumatoid arthritis of left shoulder
M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow
M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist
M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.471 Rheumatoid myopathy w rheumatoid arthritis of right ank/ft
M05.472 Rheumatoid myopathy w rheumatoid arthritis of left ank/ft
M05.49 Rheumatoid myopathy w rheumatoid arthritis of multiple sites
M05.511 Rheumatoid polyneurop w rheumatoid arthritis of r shoulder
M05.512 Rheumatoid polyneurop w rheumatoid arthritis of l shoulder
M05.521 Rheumatoid polyneurop w rheumatoid arthritis of right elbow
M05.522 Rheumatoid polyneurop w rheumatoid arthritis of left elbow
M05.531 Rheumatoid polyneurop w rheumatoid arthritis of right wrist
M05.532 Rheumatoid polyneurop w rheumatoid arthritis of left wrist
M05.541 Rheumatoid polyneurop w rheumatoid arthritis of right hand
M05.542 Rheumatoid polyneurop w rheumatoid arthritis of left hand
M05.551 Rheumatoid polyneurop w rheumatoid arthritis of right hip
M05.552 Rheumatoid polyneuropathy w rheumatoid arthritis of left hip
M05.561 Rheumatoid polyneurop w rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneurop w rheumatoid arthritis of left knee
M05.571 Rheumatoid polyneurop w rheumatoid arthritis of right ank/ft
M05.572 Rheumatoid polyneurop w rheumatoid arthritis of left ank/ft
M05.59 Rheumatoid polyneuropathy w rheumatoid arthritis mult site
M05.611 Rheu arthritis of r shoulder w involv of organs and systems
M05.612 Rheu arthritis of l shoulder w involv of organs and systems
M05.621 Rheu arthritis of r elbow w involv of organs and systems
M05.622 Rheu arthritis of l elbow w involv of organs and systems
M05.631 Rheu arthritis of r wrist w involv of organs and systems
M05.632 Rheu arthritis of l wrist w involv of organs and systems
M05.641 Rheu arthritis of right hand w involv of organs and systems
M05.642 Rheu arthritis of left hand w involv of organs and systems
M05.651 Rheu arthritis of right hip w involv of organs and systems
M05.652 Rheu arthritis of left hip w involv of organs and systems
M05.661 Rheu arthritis of right knee w involv of organs and systems
M05.662 Rheu arthritis of left knee w involv of organs and systems
M05.671 Rheu arthrit of right ank/ft w involv of organs and systems
M05.672 Rheu arthritis of left ank/ft w involv of organs and systems
M05.69 Rheu arthritis mult site w involv of organs and systems
M05.711 Rheu arthrit w rheu factor of r shoulder w/o org/sys involv
M05.712 Rheu arthrit w rheu factor of l shoulder w/o org/sys involv
M05.721 Rheu arthritis w rheu factor of r elbow w/o org/sys involv
M05.722 Rheu arthritis w rheu factor of l elbow w/o org/sys involv
M05.731 Rheu arthritis w rheu factor of r wrist w/o org/sys involv
M05.732 Rheu arthritis w rheu factor of l wrist w/o org/sys involv
M05.741 Rheu arthritis w rheu factor of r hand w/o org/sys involv
M05.742 Rheu arthritis w rheu factor of left hand w/o org/sys involv
M05.751 Rheu arthritis w rheu factor of right hip w/o org/sys involv
M05.752 Rheu arthritis w rheu factor of left hip w/o org/sys involv
M05.761 Rheu arthritis w rheu factor of r knee w/o org/sys involv
M05.762 Rheu arthritis w rheu factor of left knee w/o org/sys involv
M05.771 Rheu arthrit w rheu fctr of right ank/ft w/o org/sys involv
M05.772 Rheu arthrit w rheu factor of left ank/ft w/o org/sys involv
M05.79 Rheu arthritis w rheu factor mult site w/o org/sys involv
M05.811 Oth rheumatoid arthritis w rheumatoid factor of r shoulder
M05.812 Oth rheumatoid arthritis w rheumatoid factor of l shoulder
M05.821 Oth rheumatoid arthritis w rheumatoid factor of right elbow
M05.822 Oth rheumatoid arthritis w rheumatoid factor of left elbow
M05.831 Oth rheumatoid arthritis w rheumatoid factor of right wrist
M05.832 Oth rheumatoid arthritis w rheumatoid factor of left wrist
M05.841 Oth rheumatoid arthritis w rheumatoid factor of right hand
M05.842 Oth rheumatoid arthritis with rheumatoid factor of left hand
M05.851 Oth rheumatoid arthritis with rheumatoid factor of right hip
M05.852 Oth rheumatoid arthritis with rheumatoid factor of left hip
M05.861 Oth rheumatoid arthritis w rheumatoid factor of right knee
M05.862 Oth rheumatoid arthritis with rheumatoid factor of left knee
M05.871 Oth rheumatoid arthritis w rheumatoid factor of right ank/ft
M05.872 Oth rheumatoid arthritis w rheumatoid factor of left ank/ft
M05.89 Oth rheumatoid arthritis w rheumatoid factor mult site
M06.011 Rheumatoid arthritis w/o rheumatoid factor, right shoulder
M06.012 Rheumatoid arthritis w/o rheumatoid factor, left shoulder
M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist
M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist
M06.041 Rheumatoid arthritis without rheumatoid factor, right hand
M06.042 Rheumatoid arthritis without rheumatoid factor, left hand
M06.051 Rheumatoid arthritis without rheumatoid factor, right hip
M06.052 Rheumatoid arthritis without rheumatoid factor, left hip
M06.061 Rheumatoid arthritis without rheumatoid factor, right knee
M06.062 Rheumatoid arthritis without rheumatoid factor, left knee
M06.071 Rheumatoid arthritis w/o rheumatoid factor, right ank/ft
M06.072 Rheumatoid arthritis w/o rheumatoid factor, left ank/ft
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis w/o rheumatoid factor, multiple sites
M06.1 Adult-onset Still's disease
M06.211 Rheumatoid bursitis, right shoulder
M06.212 Rheumatoid bursitis, left shoulder
M06.221 Rheumatoid bursitis, right elbow
M06.222 Rheumatoid bursitis, left elbow
M06.231 Rheumatoid bursitis, right wrist
M06.232 Rheumatoid bursitis, left wrist
M06.241 Rheumatoid bursitis, right hand
M06.242 Rheumatoid bursitis, left hand
M06.251 Rheumatoid bursitis, right hip
M06.252 Rheumatoid bursitis, left hip
M06.261 Rheumatoid bursitis, right knee
M06.262 Rheumatoid bursitis, left knee
M06.271 Rheumatoid bursitis, right ankle and foot
M06.272 Rheumatoid bursitis, left ankle and foot
M06.28 Rheumatoid bursitis, vertebrae
M06.29 Rheumatoid bursitis, multiple sites
M06.811 Other specified rheumatoid arthritis, right shoulder
M06.812 Other specified rheumatoid arthritis, left shoulder
M06.821 Other specified rheumatoid arthritis, right elbow
M06.822 Other specified rheumatoid arthritis, left elbow
M06.831 Other specified rheumatoid arthritis, right wrist
M06.832 Other specified rheumatoid arthritis, left wrist
M06.841 Other specified rheumatoid arthritis, right hand
M06.842 Other specified rheumatoid arthritis, left hand
M06.851 Other specified rheumatoid arthritis, right hip
M06.852 Other specified rheumatoid arthritis, left hip
M06.861 Other specified rheumatoid arthritis, right knee
M06.862 Other specified rheumatoid arthritis, left knee
M06.871 Other specified rheumatoid arthritis, right ankle and foot
M06.872 Other specified rheumatoid arthritis, left ankle and foot
M06.88 Other specified rheumatoid arthritis, vertebrae
M06.89 Other specified rheumatoid arthritis, multiple sites
M08.011 Unspecified juvenile rheumatoid arthritis, right shoulder
M08.012 Unspecified juvenile rheumatoid arthritis, left shoulder
M08.021 Unspecified juvenile rheumatoid arthritis, right elbow
M08.022 Unspecified juvenile rheumatoid arthritis, left elbow
M08.031 Unspecified juvenile rheumatoid arthritis, right wrist
M08.032 Unspecified juvenile rheumatoid arthritis, left wrist
M08.041 Unspecified juvenile rheumatoid arthritis, right hand
M08.042 Unspecified juvenile rheumatoid arthritis, left hand
M08.051 Unspecified juvenile rheumatoid arthritis, right hip
M08.052 Unspecified juvenile rheumatoid arthritis, left hip
M08.061 Unspecified juvenile rheumatoid arthritis, right knee
M08.062 Unspecified juvenile rheumatoid arthritis, left knee
M08.071 Unsp juvenile rheumatoid arthritis, right ankle and foot
M08.072 Unsp juvenile rheumatoid arthritis, left ankle and foot
M08.08 Unspecified juvenile rheumatoid arthritis, vertebrae
M08.09 Unspecified juvenile rheumatoid arthritis, multiple sites
M08.211 Juvenile rheumatoid arthritis w systemic onset, r shoulder
M08.212 Juvenile rheumatoid arthritis w systemic onset, l shoulder
M08.221 Juvenile rheumatoid arthritis w systemic onset, right elbow
M08.222 Juvenile rheumatoid arthritis w systemic onset, left elbow
M08.231 Juvenile rheumatoid arthritis w systemic onset, right wrist
M08.232 Juvenile rheumatoid arthritis w systemic onset, left wrist
M08.241 Juvenile rheumatoid arthritis w systemic onset, right hand
M08.242 Juvenile rheumatoid arthritis with systemic onset, left hand
M08.251 Juvenile rheumatoid arthritis with systemic onset, right hip
M08.252 Juvenile rheumatoid arthritis with systemic onset, left hip
M08.261 Juvenile rheumatoid arthritis w systemic onset, right knee
M08.262 Juvenile rheumatoid arthritis with systemic onset, left knee
M08.271 Juvenile rheumatoid arthritis w systemic onset, right ank/ft
M08.272 Juvenile rheumatoid arthritis w systemic onset, left ank/ft
M08.28 Juvenile rheumatoid arthritis with systemic onset, vertebrae
M08.29 Juvenile rheu arthritis w systemic onset, multiple sites
M08.3 Juvenile rheumatoid polyarthritis (seronegative)
M08.40 Pauciarticular juvenile rheumatoid arthritis, unsp site
M08.411 Pauciarticular juvenile rheumatoid arthritis, right shoulder
M08.412 Pauciarticular juvenile rheumatoid arthritis, left shoulder
M08.421 Pauciarticular juvenile rheumatoid arthritis, right elbow
M08.422 Pauciarticular juvenile rheumatoid arthritis, left elbow
M08.431 Pauciarticular juvenile rheumatoid arthritis, right wrist
M08.432 Pauciarticular juvenile rheumatoid arthritis, left wrist
M08.441 Pauciarticular juvenile rheumatoid arthritis, right hand
M08.442 Pauciarticular juvenile rheumatoid arthritis, left hand
M08.451 Pauciarticular juvenile rheumatoid arthritis, right hip
M08.452 Pauciarticular juvenile rheumatoid arthritis, left hip
M08.461 Pauciarticular juvenile rheumatoid arthritis, right knee
M08.462 Pauciarticular juvenile rheumatoid arthritis, left knee
M08.471 Pauciarticular juvenile rheumatoid arthritis, right ank/ft
M08.472 Pauciarticular juvenile rheumatoid arthritis, left ank/ft
M08.48 Pauciarticular juvenile rheumatoid arthritis, vertebrae
M08.811 Other juvenile arthritis, right shoulder
M08.812 Other juvenile arthritis, left shoulder
M08.821 Other juvenile arthritis, right elbow
M08.822 Other juvenile arthritis, left elbow
M08.831 Other juvenile arthritis, right wrist
M08.832 Other juvenile arthritis, left wrist
M08.841 Other juvenile arthritis, right hand
M08.842 Other juvenile arthritis, left hand
M08.851 Other juvenile arthritis, right hip
M08.852 Other juvenile arthritis, left hip
M08.861 Other juvenile arthritis, right knee
M08.862 Other juvenile arthritis, left knee
M08.871 Other juvenile arthritis, right ankle and foot
M08.872 Other juvenile arthritis, left ankle and foot
M08.88 Other juvenile arthritis, other specified site
M08.89 Other juvenile arthritis, multiple sites
M08.911 Juvenile arthritis, unspecified, right shoulder
M08.912 Juvenile arthritis, unspecified, left shoulder
M08.921 Juvenile arthritis, unspecified, right elbow
M08.922 Juvenile arthritis, unspecified, left elbow
M08.931 Juvenile arthritis, unspecified, right wrist
M08.932 Juvenile arthritis, unspecified, left wrist
M08.941 Juvenile arthritis, unspecified, right hand
M08.942 Juvenile arthritis, unspecified, left hand
M08.951 Juvenile arthritis, unspecified, right hip
M08.952 Juvenile arthritis, unspecified, left hip
M08.961 Juvenile arthritis, unspecified, right knee
M08.962 Juvenile arthritis, unspecified, left knee
M08.971 Juvenile arthritis, unspecified, right ankle and foot
M08.972 Juvenile arthritis, unspecified, left ankle and foot
M08.98 Juvenile arthritis, unspecified, vertebrae
M08.99 Juvenile arthritis, unspecified, multiple sites

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