AM26-SU-31-L - Therapeutic Apheresis at the Edge of Evidence: Winning the Indication, the Policy, and the Peer-to-peer

Therapeutic apheresis frequently operates at the boundary between established evidence and urgent clinical need. While many procedures are supported by well-defined indications and consensus guidelines, clinicians increasingly encounter situations where evidence is limited, evolving, or outside traditional reimbursement frameworks. In these cases, successful patient care depends not only on clinical judgment but also on navigating coding structures, payer policies, and formal appeals processes.
This session provides a practical, step-by-step framework for managing therapeutic apheresis cases that fall outside clearly established indications. Using real-world examples, panelists will examine how apheresis programs can successfully navigate the operational and administrative pathways required to deliver care in these complex scenarios.
The session will address three critical stages in the process. First, Dr. Godbey will discuss how apheresis procedure code reimbursement values are determined. Second, Carrie Karlene, an apheresis nurse leader will review the operational process of obtaining pre-authorization, including documentation requirements, coordination with payers, and common barriers encountered by clinical teams. Finally, Dr. Lance Williams, will outline strategies for constructing effective appeals and peer-to-peer discussions when coverage is denied, including how to frame evidence, clinical urgency, and mechanistic rationale.
By integrating clinical, operational, and policy perspectives, this session will equip therapeutic apheresis programs with practical tools to advocate for appropriate patient care while maintaining compliance, program sustainability, and responsible stewardship of healthcare resources.