38215
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.92
Facility
$40.42
Non-Facility
$40.42
Documentation Required
- Documentation that the patient has rapidly progressive scleroderma (systemic sclerosis) (ICD-10: M34.0 - M34.9).
- Detailed prior treatment history including dates and duration (for example, prior cyclophosphamide exposure duration is relevant — some trials excluded >6 months prior cyclophosphamide).
- Specialist evaluation and selection documentation: recommendation and multidisciplinary expert assessment that benefits outweigh risks (eg, EULAR: "Careful evaluation of the benefit to risk ratio in individual patients with SSc selected for HSCT should be done by experts").
- Center/physician experience documentation: treatment to be performed in experienced transplant centers with HSCT expertise and infrastructure.
Key Coverage Criteria
- Retinal degenerative diseases / RPE-associated disorders (e.g., ARMD, inherited retinal diseases, retinitis pigmentosa, Leber congenital amaurosis): human pluripotent stem cell (hPSC)-based retinal organoid approaches and cell-based RPE therapies are under preclinical/early clinical development and proposed as therapeutic candidates (M'Barek et al. 2019; Singh et al. 2021).
- Autism spectrum disorder (children age ~2–7 years) — single intravenous infusion of autologous or allogeneic umbilical cord blood (UCB) evaluated for safety and efficacy in phase I and phase II trials.
- Stiff‑person spectrum disorder (SPSD) — autologous non‑myeloablative hematopoietic stem cell transplantation (AHSCT) studied in a prospective open‑label pilot trial with a subset of responders.
- Retinal degenerative diseases (age‑related macular degeneration [ARMD], inherited retinal diseases including retinitis pigmentosa, Leber congenital amaurosis) — pluripotent stem cell‑based retinal organoid therapies described as preclinical/early translational approaches.
- Ankylosing spondylitis (AS) and Sjogren's syndrome (SS) — mesenchymal stem cell (MSC) therapies reported in systematic reviews and small studies with suggested clinical/immunologic improvements.
- Inflammatory myopathies (dermatomyositis, polymyositis), chronic inflammatory demyelinating polyneuropathy (CIDP), myasthenia gravis (refractory MG), neuromyelitis optica spectrum disorder (NMOSD) — hematopoietic stem cell transplantation (HSCT/AHSCT) reported in case series, trials and reviews as a potential therapy for refractory cases.
20 Active Policies
AMBETTER-CP.MP.141 — Nonmyeloablative Allogeneic Stem Cell Transplants
AETNA-CPB-0190 — Stem Cells for Hematopoietic Cell Transplant
AETNA-CPB-0606 — Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications
ANTHEM-MP-A047560 — TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
ANTHEM-MP-A070096
Related Codes
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