Extracorporeal Photopheresis — NCD 113 | CMS Coverage Update

CMS modified NCD 113 for extracorporeal photopheresis, effective March 7, 2026. Here's what billing teams need to know.

The Centers for Medicare & Medicaid Services updated its extracorporeal photopheresis coverage policy under NCD 113 (policy key 113-v3). This modification refines when Medicare covers this procedure — and the three covered indications carry very different documentation and reimbursement requirements. Extracorporeal photopheresis billing is narrow by design. If your claims don't map precisely to the covered indications, you'll face claim denial.

Quick-Reference Table

CMS Extracorporeal Photopheresis Coverage Criteria and Medical Necessity Requirements 2026

NCD 113 is the National Coverage Determination governing Medicare coverage of extracorporeal photopheresis. The policy covers the procedure under three distinct indications, each with its own effective date and medical necessity criteria. Get them confused and you're billing the wrong indication — which is a fast path to denial.

Here's how the procedure works clinically, because the mechanism matters to documentation. A patient's blood is drawn and centrifuged to isolate white blood cells. Those cells are exposed to 8-methoxypsoralen (8-MOP) — either administered directly to the isolated cells ex vivo, or given to the patient before the cells are withdrawn. The cells then receive ultraviolet A (UVA) light exposure and are re-infused into the patient. Every step of this process should be reflected in your clinical documentation.

Indication 1 — Cutaneous T-Cell Lymphoma (effective April 8, 1988)

Medicare covers extracorporeal photopheresis as palliative treatment for skin manifestations of cutaneous T-cell lymphoma. The critical medical necessity requirement: the lymphoma must not have responded to other therapy. This is a treatment-refractory standard. Document prior treatment attempts and their outcomes before you bill for this indication. Without that paper trail, your claim doesn't have a medical necessity leg to stand on.

Indication 2 — Cardiac and Graft-Versus-Host Indications (effective December 19, 2006)

Medicare covers two conditions under this tranche. First, patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment. Second, patients with chronic graft-versus-host disease (GVHD) that is also refractory to standard immunosuppressive therapy. Both require documented failure of standard immunosuppression before extracorporeal photopheresis becomes a covered service.

The word "refractory" is doing a lot of work in both indications. Your documentation must show what immunosuppressive regimens the patient received, at what doses, and why those regimens failed. Vague clinical language here creates denial risk. Be specific.

Indication 3 — Bronchiolitis Obliterans Syndrome Following Lung Transplant (effective April 30, 2012)

This one is the most complex, and the most likely to trip up billing teams. Medicare covers extracorporeal photopheresis for bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation — but only when the procedure is provided under a qualifying clinical research study. This is a Coverage with Evidence Development (CED) situation. The procedure is not broadly covered for BOS. It's covered only within the research context.

The qualifying research study must meet specific standards. The principal purpose must be testing whether the procedure improves patient health outcomes. The study must be well-supported by scientific and medical information. It must not duplicate existing studies. The design must be appropriate for the research question. The sponsoring organization must be capable of executing the study. And the study must comply with all applicable federal regulations for human subjects research — 45 CFR Part 46, and where FDA-regulated, 21 CFR parts 50 and 56.

The research must address at least one of three patient-centered outcome questions: Does the procedure improve FEV1 (forced expiratory volume in one second)? Does it improve survival after transplant? Does it improve quality of life? If the study doesn't address one of those questions, the clinical research study does not qualify — and neither does your claim.

Prior authorization requirements for extracorporeal photopheresis billing may apply at the Medicare Administrative Contractor (MAC) level. Check with your regional MAC, because local coverage determination policies can add requirements on top of this NCD.

CMS Extracorporeal Photopheresis Exclusions and Non-Covered Indications

The coverage policy is intentionally limited. Any extracorporeal photopheresis claim that doesn't fall under one of the three covered indications is not a covered Medicare service. There is no general Medicare coverage for this procedure outside of cutaneous T-cell lymphoma, refractory cardiac allograft rejection, refractory chronic GVHD, and BOS within a qualifying clinical trial.

For BOS specifically, billing outside of a qualifying research study is a non-covered service. This is a common error pattern for transplant programs that use the procedure clinically but haven't confirmed they're operating within a study that meets CMS's research standards. If the study doesn't meet all eight scientific integrity requirements in NCD 113, the reimbursement claim fails.

Coverage Indications at a Glance

CMS Extracorporeal Photopheresis Billing Guidelines and Action Items 2026

The effective date of March 7, 2026 means this modified policy is already in play. Don't wait to audit your active cases.

CPT, HCPCS, and ICD-10 Codes for Extracorporeal Photopheresis Under NCD 113

The policy data for NCD 113 does not list specific CPT or HCPCS codes. This is not unusual for older NCDs that predate standardized code-level billing guidelines.

Work with your coding team and MAC to confirm which codes apply to your claims. The procedure involves blood processing, drug administration (8-MOP), UVA light treatment, and re-infusion — each of which may carry its own billing component depending on your payer contract and MAC guidance.

If you're uncertain which codes your MAC expects for extracorporeal photopheresis billing, request written guidance from your MAC before submitting claims. Document that guidance and keep it in your billing records. A claim denial is much harder to appeal without a paper trail showing you sought clarification.

Your coding team should also look at ICD-10-CM diagnosis code specificity for the covered indications. Cutaneous T-cell lymphoma, cardiac allograft rejection, graft-versus-host disease, and bronchiolitis obliterans syndrome each have specific ICD-10 codes — and the right code matters for medical necessity matching. Don't let a diagnosis code mismatch create a denial on a claim that was otherwise correctly billed.