38210
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
1.53
Facility
$67.80
Non-Facility
$67.80
Documentation Required
- Pre-transplant laboratory: serum bilirubin result.
- Pre-transplant hemostasis: INR result with notation if patient is on oral anticoagulant therapy.
- Cardiac assessment: MUGA scan or echocardiogram report documenting ejection fraction.
- Pulmonary function testing: PFT results including FEV1 percent predicted and DLCO percent predicted.
Key Coverage Criteria
- Chronic granulomatous disease
- Allogeneic (ablative and non-myeloablative) hematopoietic stem cell transplantationis consideredmedically necessaryfor individuals with the following disorders. In addition, individuals with Sickle Cell Disease or Thalassemia should meet the Disease Specific Criteria below.
- Bone Marrow Failure SyndromesAcquired aplastic anemia (drug, idiopathic, immune disorder, toxin or viral infection)Heritable bone marrow syndromes:Congenital amegakaryocytic thrombocytopenia (CAMT)Diamond-Blackfan anemia (DBA)Dyskeratosis congenitaFanconiâs anemia (FA)Schwachman-Diamond syndrome (SDS)Paroxysmal nocturnal hemoglobinuria (PNH)
- Acquired aplastic anemia (drug, idiopathic, immune disorder, toxin or viral infection)
- Heritable bone marrow syndromes:Congenital amegakaryocytic thrombocytopenia (CAMT)Diamond-Blackfan anemia (DBA)Dyskeratosis congenitaFanconiâs anemia (FA)Schwachman-Diamond syndrome (SDS)
- Congenital amegakaryocytic thrombocytopenia (CAMT)
20 Active Policies
ANTHEM-MP-A047560 — TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
ANTHEM-MP-A070096 — TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
ANTHEM-MP-A053844 — TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
ANTHEM-MP-A053842 — TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
Related Codes
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