0264T — Im b1 mrw cel ther xcl hrvst
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Use validated outcome measures to assess quality of life (QOL) and functional ability.
- Document baseline and follow-up outcome measures to determine whether the condition improves, worsens, or remains stable and whether change is clinically significant.
- Document assessment of net health outcome, including a balance of anticipated benefits and potential harms for the specific clinical condition.
- Follow-up visits at approximately 3, 6, and 12 months after stem cell therapy to monitor outcomes (overall survival, symptoms, disease status, morbid events, functional outcomes, QOL, treatment-related morbidity including amputation rates, wound/ulcer healing, and pain-free walking distance)
Key Coverage Criteria
- Treatment of peripheral arterial disease (PAD), including critical limb ischemia characterized by ischemic rest pain, ulcers, or significant risk for limb loss
- Use of stem cell therapy as a treatment option for individuals with peripheral arterial disease (PAD).
- Hematopoietic or bone marrow–derived cell therapy intended to induce arteriogenesis in PAD by augmenting physiologic repair processes.
- Peripheral arterial disease presenting as severe, limb-threatening ischemia.
- Patients in whom revascularization has failed.
- Patients for whom revascularization is not possible and who are at risk of amputation.
6 Active Policies
BCBSIL-SUR703.048 — Stem Cell Therapy for Peripheral Arterial Disease
BCBSMT-SUR703.048 — Stem Cell Therapy for Peripheral Arterial Disease
BCBSNM-SUR703.048 — Stem Cell Therapy for Peripheral Arterial Disease
BCBSOK-SUR703.048 — Stem Cell Therapy for Peripheral Arterial Disease
REGENCE-MED141 — Cell Therapy for Peripheral Arterial Disease
Related Codes
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