Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 15102 | CGS Administrators, LLC | MAC - Part B | KY |
| 15202 | CGS Administrators, LLC | MAC - Part B | OH |
| 15101 | CGS Administrators, LLC | MAC - Part A | KY |
| 15201 | CGS Administrators, LLC | MAC - Part A | OH |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57160 (Billing and Coding: Immune Thrombocytopenia (ITP) Therapy) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57160: Billing and Coding: Immune Thrombocytopenia (ITP) Therapy (Billing and Coding, effective 2026-04-16)
- Covered ICD-10-CM codes
- 1
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 20
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| D69.3 | — |
Procedure codes: 38100, 38120, 90283, J1459 (Injection, Immune Globulin (Privigen), Intravenous, Non-Lyophilized (E.G., Liquid), 500 Mg), J1460 (Injection, Gamma Globulin, Intramuscular, 1 Cc), J1556 (Injection, Immune Globulin (Bivigam), 500 Mg), J1557 (Injection, Immune Globulin, (Gammaplex), Intravenous, Non-Lyophilized (E.G., Liquid), 500 Mg), J1560 (Injection, Gamma Globulin, Intramuscular, Over 10 Cc), J1561 (Injection, Immune Globulin, (Gamunex-C/Gammaked), Non-Lyophilized (E.G., Liquid), 500 Mg), J1566 (Injection, Immune Globulin, Intravenous, Lyophilized (E.G., Powder), Not Otherwise Specified, 500 Mg), J1568 (Injection, Immune Globulin, (Octagam), Intravenous, Non-Lyophilized (E.G., Liquid), 500 Mg), J1569 (Injection, Immune Globulin, (Gammagard Liquid), Non-Lyophilized, (E.G., Liquid), 500 Mg), J1572 (Injection, Immune Globulin, (Flebogamma/Flebogamma Dif), Intravenous, Non-Lyophilized (E.G., Liquid), 500 Mg), J1599 (Injection, Immune Globulin, Intravenous, Non-Lyophilized (E.G., Liquid), Not Otherwise Specified, 500 Mg), J2788 (Injection, Rho D Immune Globulin, Human, Minidose, 50 Micrograms (250 I.U.)), J2790 (Injection, Rho D Immune Globulin, Human, Full Dose, 300 Micrograms (1500 I.U.)), J2791 (Injection, Rho(D) Immune Globulin (Human), (Rhophylac), Intramuscular Or Intravenous, 100 Iu), J2792 (Injection, Rho D Immune Globulin, Intravenous, Human, Solvent Detergent, 100 Iu), J8499 (Prescription Drug, Oral, Non Chemotherapeutic, Nos), J9312 (Injection, Rituximab, 10 Mg).
Coverage indications, limitations and medical necessity
Treatment of Primary Immune Thrombocytopenia (ITP)
Treatment
Treatment is not medically necessary in the following scenarios:
• Children with no bleeding or mild bleeding (skin manifestations only such as bruising and petechiae) regardless of platelet count
• Adults with platelet count ≥ 30 x10 9 /L in the absence of bleeding
Treatment may be indicated with documentation of at least one of the following conditions:
• Severe ITP (bleeding)
• Adult with platelets count ≤30 x10 9 /L especially if risk factors for bleeding are present
• In preparation for procedures or surgery with risk of bleeding
• Professional or lifestyle risk factors for trauma
Risk factors for bleeding include predisposing comorbidities that increase the risk of bleeding such as uncontrolled hypertension, active peptic ulcer disease, anticoagulation, recent surgery, or head trauma.
First-Line Therapy
First-line pharmacologic treatment in children and adults is corticosteroids in dosing regimens standard to ITP treatment.
Intravenous Immune globulin (IVIg) may be used first-line with documentation of at least one of the following conditions:
• Documented need for rapid response (
Lack of response is defined as platelet count 9 /L or less than 2-fold increase in baseline platelets 1 .
Intravenous anti-D may be used first-line in adults with documentation of at least one of the following conditions in patients who are Rh positive and nonsplenectomized:
• Documented need for rapid response (
Second-Line Treatment
Coverage of second-line treatment requires a documented lack of response to at least one first-line therapy. Shared decision making to consider the risk and benefit of the various second-line options should be documented in the medical record. This should include a discussion of surgical and non-surgical options.
Splenectomy will be covered when all of the following criteria are met:
• Documented lack of response of at least one first-line therapy
• Documented risk for bleeding (at least one of the following)
• Severe ITP (bleeding symptoms)
• Adult with platelets count ≤30 x10 9 /L especially if risk factors for bleeding are present
• In preparation for procedures or surgery with risk of bleeding
• Professional or lifestyle risk for trauma
• Persistent or chronic disease (>6 months) OR documented indication for more immediate surgical intervention (
Thrombopoietin receptor agonist (TPO-RA) will be covered when all of the following criteria are met:
• Documented lack of response of at least one first-line therapy
• Documented risk for bleeding (at least one of the following)
• Severe ITP (bleeding symptoms)
• Risk factors for bleeding are present
• In preparation for procedures or surgery with risk of bleeding
• Professional or lifestyle risk factors for trauma
• Persistent or chronic disease (>6 months)
Rituximab will be covered when all of the following criteria are met:
• Documented lack of response of at least one first line therapy
• Documented risk for bleeding (at least one of the following)
• Severe ITP (bleeding symptoms)
• Risk factors for bleeding are present
• In preparation for procedures or surgery with risk of bleeding
• Professional or lifestyle risk for trauma
• Persistent or chronic disease (>6 months)
Summary of evidence (opening)
Primary immune thrombocytopenia (ITP) is an acquired immune-mediated disorder characterized by isolated thrombocytopenia, defined as a peripheral blood platelet count less than 100 x 10 9 /L in the absence of other underlying causes 2 . The incidence ranges from 1-5 per 100,000 adults, but prevalence is higher due to the chronic nature of the disorder 3,4 . International consensus classifies ITP by duration into newly diagnosed ( 1 .
ITP can occur in both the pediatric and adult populations. In children, the disease typically acute following a viral illness and is usually self-limited remitting spontaneously within six months with about 15% developing chronic ITP 5 . In adults, ITP is extremely heterogeneous, ranging from asymptomatic to severe bleeding. For most adults, the morbidity and mortality related to ITP are low and severe bleeding is rare 5 . Risk of serious bleeding is increased when platelet counts are less than 30 x 10 9 /L, platelets remain persistently low, increasing age, medical comorbidities, and failure to respond to treatment 5 6,7 . In the subset of patients at high risk for life-threatening bleeding, the goal of therapy is the prevention of severe bleeding including potentially life-threatening bleeding such as intracranial hemorrhage, gastrointestinal bleeding, or skin and mucosal hemorrhage. Patients with persistent severe thrombocytopenia that does not respond to therapy within the first two years have considerable morbidity and a 6-fold increase in mortality 8 .
Various terminologies have been used in the literature on ITP, which has made it more difficult to compare studies as definitions are variable. International consensus defined the following: Severe ITP is defined as the presence of bleeding symptoms or occurrence of new bleeding symptoms requiring additional therapeutic intervention usually with platelet counts 9 /L 1,2 . A response is defined as platelet count ≥30 x10 9 /L but ≤100 x 10 9 /L 1 and at least doubling of the baseline platelet count and a complete response defined as platelet count >100 x 10 9 /L 1 . Lack of response is defined as platelet count 9 /L or less than 2-fold increase in baseline platelets and loss of response is defined as platelet count 9 /L or less than 2-fold increase in baseline platelets following a response 1 .
The goal of treatment is to prevent severe bleeding, but the risk of bleeding can be difficult to estimate. Individual considerations, including risk factors and lifestyle, must be considered. Treatment is rarely indicated in patients with platelet counts above 30 x 10/ 9 L and should be based on symptoms and signs rather than arbitrary platelet threshold 2,9 . The balance between the risk of bleeding and treatment itself must be considered as overall morbidity and mortality may be increased with treatment 8 . Treatment is not medically necessary in children with no bleeding or mild bleeding (skin manifestations only such as bruising and petechiae) regardless of platelet count (grade 1B) or adults with platelet count ≥ 30 x10 9 /L in the absence of bleeding (grade 2C) 10 . Treatment is clearly indicated in the setting of severe ITP (bleeding) and in preparation for procedures or surgery with risk of bleeding and may also be indicated in an adult with platelets count ≤30 x10 9 /L (grade 2C) especially if risk factors for bleeding are present. Predisposing comorbidities such as uncontrolled hypertension, active peptic ulcer disease, anticoagulation, recent surgery or head trauma or lifestyle risk factors may increase the risk of bleeding 10,11 .
The contractor cites 43 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2020-04-01
- Current revision effective
- 2026-03-05
- Last reviewed by the contractor
- 2025-02-25
- MCD version
- 11
Other related documents: A57929 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the CGS Administrators, LLC hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L38268 cover?
• Children with no bleeding or mild bleeding (skin manifestations only such as bruising and petechiae) regardless of platelet count The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L38268 apply to?
CGS Administrators, LLC applies it to Medicare claims in KY, OH. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L38268?
The companion billing and coding article A57160 lists 1 ICD-10-CM codes in 1 group that support medical necessity; the first 1 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38268?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.