38206
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
$67.47
Non-Facility
$67.47
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.)
- Note (from policy): Factors associated with increased risk of stroke or end-organ damage include recurrent chest syndrome, recurrent vaso-occlusive crises, and red blood cell alloimmunization on chronic transfusion therapy.
- ICD-10 codes listed as covered diagnoses (per CPB): D56.1 (Beta thalassemia); D57.00 - D57.819 (Sickle-cell disorders).
- Covered ICD-10 diagnoses associated with the selection criteria: D56.1 (Beta thalassemia) and D57.00 - D57.819 (Sickle-cell disorders).
- Aetna considers allogeneic hematopoietic cell transplantation medically necessary for the following: For the treatment of thalassemia major (i.e., homozygous beta-thalassemia) in children or young adults (to age 45 years) when the member meets transplanting institution's written eligibility criteria.
20 Active Policies
AETNA-CPB-0163 — Transmyocardial and Endovascular Laser Revascularization
AETNA-CPB-0423 — Alopecia Areata
AETNA-CPB-0606 — Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications
AETNA-CPB-0626 — Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia
AETNA-CPB-0654 — Ventricular Assist Devices
Related Codes
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