38207
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.87
Facility
$38.08
Non-Facility
$38.08
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.)
- ICD-10 codes covered if selection criteria are met: Z94.84 (Stem cells transplant status).
- ICD-10 codes covered if selection criteria are met: C92.10 - C92.12 (Chronic myeloid leukemia, BCR/ABL-positive).
- ICD-10 codes covered if selection criteria are met: Z94.81 (Bone marrow transplant status).
- Donor lymphocyte infusion (DLI) is considered medically necessary for persons who have a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation.
20 Active Policies
AETNA-CPB-0606 — Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications
AETNA-CPB-0638 — Donor Lymphocyte Infusion
UHC-POL-umbilical-cord-blood-harvesting-and-storage-future-use — Umbilical Cord Blood Harvesting and Storage for Future Use
UMR-POL-UMR-umbilical-cord-blood-harvesting-and-storage-future-use — Umbilical Cord Blood Harvesting and Storage for Future Use
Related Codes
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