86817
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
- Bone marrow biopsy/cellularity report documenting marrow cellularity (required to demonstrate cellularity <25% where applicable).
- Transplanting institution's selection criteria or statement that the member meets the transplant center's selection criteria (if such criteria exist).
- Peripheral blood counts documenting neutrophil count, platelet count, and reticulocyte count (to demonstrate neutrophils <0.5 x 10^9/L, platelets <20 x 10^9/L, reticulocyte <1% or <20 x 10^9/L as applicable).
- Transfusion history (to document ongoing transfusion requirements, transfusion dependence, or 'untransfused' platelet count as relevant).
Key Coverage Criteria
- Allogeneic hematopoietic cell transplantation (HCT) is medically necessary for the treatment of severe aplastic anemia when members meet the transplanting institution's selection criteria.
- Allogeneic HCT for Diamond-Blackfan anemia in persons who are refractory to corticosteroids.
- Allogeneic HCT for severe aplastic anemia when the member has at least 3 of the following 4 features: (1) Bone marrow cellularity less than 25% (markedly hypocellular); (2) Neutrophil count less than 0.5 x 10^9/L; (3) Reticulocyte count less than 1% or less than 20 x 10^9/L (corrected for hematocrit); (4) Untransfused platelet count less than 20 x 10^9/L.
- Allogeneic HCT for pure red cell aplasia when the member has: (1) Bone marrow cellularity less than 25% (markedly hypocellular) AND (2) Reticulocyte count less than 1% or less than 20 x 10^9/L (corrected for hematocrit).
- Allogeneic HCT for Fanconi's anemia in persons with severe bone marrow failure, myelodysplastic syndrome (MDS), or acute myelogenous leukemia (AML).
- Allogeneic HCT for paroxysmal nocturnal hemoglobinuria (PNH) with ongoing transfusion requirements and a suitable human leukocyte antigen (HLA)-matched donor.
20 Active Policies
AETNA-CPB-0497 — Hematopoietic Cell Transplantation for Multiple Myeloma
AETNA-CPB-0348 — Recurrent Pregnancy Loss
AETNA-CPB-0626 — Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia
AETNA-CPB-0627 — Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes
BCBSIL-SUR703.029 — Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
Related Codes
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