50325
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Refer to separate policy CP.MP.250 for criteria related to Lantidra (donislecel) allogeneic pancreatic islet cellular therapy.
- Serial blood and urine testing may be required to verify abstinence from substances of concern.
- Documentation of a commitment to reduce substance-use behaviors is acceptable when urgent transplant timelines exist (as evidence of risk-reduction intent).
- Chart notes, emergency department records, or hospitalization records documenting the recurrent severe metabolic complications and specifying the type (e.g., hypoglycemia unawareness, severe hypoglycemic attacks, marked hyperglycemia, recurrent ketoacidosis).
Key Coverage Criteria
- Scleroderma
- Polyarteritis (periarteritis nodosa)
- Multiple Myeloma
- Lupus Erythematosus
- Macroglobulinemia
- Wegner's Disease
9 Active Policies
AMBETTER-CP.MP.102 — Pancreas Transplantation
AMBETTER-CP.MP.246 — Pediatric Kidney Transplant
ANTHEM-GL-A051131 — Status
ANTHEM-MP-A046252 — Pre-Merger Organizations
BCBSIL-SUR703.007 — Kidney Transplant
Related Codes
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