Does 38228 require prior authorization?

No, 38228 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 38228?

Medicare facility rate: $149.97. Non-facility rate: $318.98. Work RVU: 3.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.00

Facility

$149.97

Non-Facility

$318.98

General requirement that documentation must support medical necessity per Medicare standards (medical records, clinical notes, diagnostic test results, treatment history) although no product-specific documentation items are listed in this document chunk.
Documentation and clinical criteria referenced in the specific Humana Pharmacy Coverage Policies for Abecma, Aucatzyl, Breyanzi, and Carvykti should be provided when requesting coverage for those agents.
No specific documentation requirements (medical records, test results, or clinical notes) are provided in the provided excerpt; the excerpt contains a 'Coding Information' heading but does not list required documentation. See full Humana policy for detailed documentation requirements.
No documentation requirements are specified in this excerpt.

38227 - Chimeric antigen receptor T cell (CAR T) therapy; receipt and preparation of CAR T cells for administration
38228 - Chimeric antigen receptor T cell (CAR T) therapy; CAR T cell
Chimeric antigen receptor T-cell (CAR-T) therapy: harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells (CPT Category III code 0537T).
Chimeric antigen receptor T-cell (CAR-T) therapy services as represented by listed CPT codes: 0538T (preparation of blood-derived T lymphocytes for transportation, e.g., cryopreservation, storage), 0539T (receipt and preparation of CAR-T cells for administration), and 0540T (CAR-T cell administration, autologous).
Administration and supply of specific CAR-T products represented by listed HCPCS/Q-codes: Q2041 (Axicabtagene ciloleucel), Q2042 (Tisagenlecleucel), Q2053 (Brexucabtagene autoleucel), Q2054 (Lisocabtagene maraleucel), Q2055 (Idecabtagene vicleucel), Q2056 (Ciltacabtagene autoleucel), Q2058 (Obecabtagene autoleucel, per infusion), and C9301 (Obecabtagene autoleucel, up to 410 million CD19 CAR-positive viable T cells, per therapeutic dose).
Use of not otherwise classified antineoplastic agents when billed to J9999 (as listed).

HUMANA-CHIMERIC-ANTIGEN-RECEPTOR-CAR-T-CELL-THERAPY-MA — Chimeric Antigen Receptor (CAR) T-cell Therapy - Medicare Advantage

Ask Verity about documentation requirements, denial risks, or coverage in your state.