Does 86923 require prior authorization?

No, 86923 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 86923?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

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).

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.

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

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