38205
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
1.46
Facility
$68.81
Non-Facility
$68.81
Documentation Required
- "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan."
- "Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- No explicit clinical documentation requirements (e.g., required test results, clinical notes or prior authorization documentation) are specified in this policy for cord blood harvesting or storage; the policy directs that coverage of cord blood stem cell transplantation is addressed in the Optum Clinical Guideline titled Hematopoietic Stem Cell Transplantation.
- If directed/family banking is being considered, supporting documentation (not specified in policy) would be expected to include evidence of a family member's diagnosable condition that is potentially treatable with cord blood transplantation (policy cites society guidance recommending directed banking in such cases).
Key Coverage Criteria
- No covered prophylactic indication specified. "Due to insufficient evidence of efficacy, prophylactic collection and storage of umbilical cord blood is unproven and not medically necessary for an individual who is currently healthy but desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation."
- No other explicit covered indications are stated in this policy. (Policy directs to the Optum Clinical Guideline titled Hematopoietic Stem Cell Transplantation for additional information and coverage of umbilical cord blood stem cell transplantation.)
- Extensive alopecia areata (involving more than 50 % loss of scalp hair) — treatments may include topical immunotherapy, systemic agents or other measures: "Therapy for extensive alopecia areata (involving more than 50 % loss of scalp hair) may be prolonged and difficult...Systemic corticosteroids are seldom used due to their adverse effects; however, they may be required depending on the severity of the condition and the adequacy of the response to topical therapy."
- Topical immunotherapy (DPCP/DCP and SADBE) for scalp hair loss of 50 to 99 % — "Topical immunotherapy...with reported hair growth rates of 40 to 60 % among patients with scalp hair loss of 50 to 99 %."
- Psoralen photochemotherapy (PUVA) as an option for alopecia areata (used in practice by AAD despite limited evidence) — "Psoralen photochemotherapy (psoralen and ultraviolet light A or PUVA) is another immunosuppressant treatment that is used for alopecia areata...Despite these limitations, PUVA is still considered standard practice of care by the American Academy of Dermatology."
- Topical 5% minoxidil for patchy alopecia areata — meta-analysis finding: "The meta-analysis involving 5% minoxidil versus placebo presented a significant difference in favor of 5% minoxidil...in children and adults with patchy AA."
20 Active Policies
AMBETTER-CP.MP.141 — Nonmyeloablative Allogeneic Stem Cell Transplants
AMBETTER-CP.MP.162 — Tandem Transplant
AETNA-CPB-0423 — Alopecia Areata
AETNA-CPB-0496 — Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors
AETNA-CPB-0606 — Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications
Related Codes
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