96401
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.21
Facility
$71.81
Non-Facility
$71.81
Documentation Required
- Documentation of histologic diagnosis of testicular cancer (pathology report).
- Documentation of staging (clinical stage I–III as applicable) including imaging (CT scans) and any laparotomy reports as applicable.
- Serum tumor marker results (HCG and AFP) before and after initial therapy and at time of consideration for transplant to document response or relapse.
- Detailed records of initial course of standard-dose chemotherapy (drugs used, number of cycles) and objective documentation of response to that therapy (complete remission status, partial response defined as at least 50% reduction in tumor burden, or refractory defined as <50% reduction in tumor burden).
Key Coverage Criteria
- CPT/HCPCS billing that are covered if selection criteria are met: CPT 38206-38230 (Bone marrow or stem cell services/procedures (except allogenic)), CPT 38241 (Hematopoietic progenitor cell (HPC); autologous transplantation), chemotherapy administration CPT 96401-96549, and HCPCS S2150 (Bone marrow or blood-derived stem cells ... allogeneic or autologous ... [...]
- Autologous hematopoietic cell transplantation for the treatment of persons with testicular cancer who do not attain a complete remission after an initial course of standard-dose chemotherapy, i.e., those with refractory (less than 50 % reduction in tumor burden) testicular cancer or those exhibiting a partial response (at least a 50 % reduction in tumor burden);
- Autologous hematopoietic cell transplantation as consolidation therapy for persons with testicular cancer who relapse after an initial course of standard-dose chemotherapy;
- Tandem autologous hematopoietic cell transplantation for persons with testicular cancer who have relapsed.
- Covered ICD-10 diagnoses (when selection criteria are met): C62.00 - C62.92 (Malignant neoplasm of testis) and D07.69 (Carcinoma in situ of other male genital organs [testis]).
- CPT/HCPCS services covered if selection criteria are met (per policy): 38206-38230 (bone marrow or stem cell services/procedures except allogeneic), 38241 (Hematopoietic progenitor cell (HPC); autologous transplantation), 96401-96549 (chemotherapy administration), and HCPCS S2150 (bone marrow or blood-derived stem cells... harvesting, transplantation, and related complications).
3 Active Policies
AETNA-CPB-0024 — Aldesleukin (Proleukin)
AETNA-CPB-0290 — Scalp Cooling (Hypothermia) to Prevent Hair Loss During Chemotherapy
AETNA-CPB-0617 — Hematopoietic Cell Transplantation for Testicular Cancer
Related Codes
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