Does 38240 require prior authorization?

No, 38240 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 38240?

Medicare facility rate: $201.74. Non-facility rate: $201.74. Work RVU: 3.90.

Verity

`38240`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

3.90

Facility

$201.74

Non-Facility

$201.74

Documentation Required

Medical record must include disease-specific restaging studies and any further studies indicated by signs or symptoms.
Medical record must contain all relevant laboratory studies supporting transplant eligibility and staging.
Medical record must include a chest radiograph, an electrocardiogram, and a study of cardiac function.
Medical record must include pulmonary function testing (PFT) results as part of the pretransplant evaluation.

Key Coverage Criteria

Allogeneic hematopoietic cell transplantation (HCT) is covered for beneficiaries with primary refractory Hodgkin lymphoma.
Allogeneic HCT is covered for beneficiaries with relapsed Hodgkin lymphoma.
Allogeneic HCT is covered for beneficiaries with primary refractory or relapsed Non-Hodgkin lymphoma of B-cell origin.
Allogeneic HCT is covered for beneficiaries with primary refractory or relapsed Non-Hodgkin lymphoma of T-cell origin.
Allogeneic hematopoietic cell transplantation is covered for primary refractory or relapsed Hodgkin's lymphoma and relapsed or refractory non-Hodgkin's lymphoma of B-cell or T-cell origin as an additional locally covered indication complementary to LCD L39396 and consistent with NCD 110.23.
Allogeneic hematopoietic cell transplantation (HCT) may be locally covered for primary refractory or relapsed Hodgkin lymphoma and non-Hodgkin lymphoma of B-cell or T-cell origin as specified by this article in conjunction with LCD L39398 and NCD 110.23.

20 Active Policies

A59259 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

J05

L39477 — Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

J05

L39513 — Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin

J06

A59311 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin

J06

Have a follow-up question?

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

Medical record must include a detailed history and physical examination documenting extent of disease and comorbidities relevant to transplant outcomes.

Documentation of completion of the institution’s pre-established pre-transplant protocol or documentation that the required protocol elements were completed must be included in the record.

AETNA-CPB-0496 — Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors

AETNA-CPB-0606 — Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications

AMBETTER-CP.MP.162 — Tandem Transplant

AETNA-CPB-0779 — Plerixafor

AETNA-CPB-0389 — Hypertrophic Scars and Keloids

AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments

A59042 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

A59175 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

A59177 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

A59215 — Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

L39270 — Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

AETNA-CPB-0674 — Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia

AETNA-CPB-0635 — Hematopoietic Cell Transplantation for Ovarian Cancer

L39396 — Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

L39398 — Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

AETNA-CPB-0195 — Erythropoiesis Stimulating Agents

38240