G0267
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Key Coverage Criteria
- Chronic granulomatous disease
- Allogeneic (ablative and non-myeloablative) hematopoietic stem cell transplantationis consideredmedically necessaryfor individuals with the following disorders. In addition, individuals with Sickle Cell Disease or Thalassemia should meet the Disease Specific Criteria below.
- Bone Marrow Failure SyndromesAcquired aplastic anemia (drug, idiopathic, immune disorder, toxin or viral infection)Heritable bone marrow syndromes:Congenital amegakaryocytic thrombocytopenia (CAMT)Diamond-Blackfan anemia (DBA)Dyskeratosis congenitaFanconiâs anemia (FA)Schwachman-Diamond syndrome (SDS)Paroxysmal nocturnal hemoglobinuria (PNH)
- Acquired aplastic anemia (drug, idiopathic, immune disorder, toxin or viral infection)
- Heritable bone marrow syndromes:Congenital amegakaryocytic thrombocytopenia (CAMT)Diamond-Blackfan anemia (DBA)Dyskeratosis congenitaFanconiâs anemia (FA)Schwachman-Diamond syndrome (SDS)
- Congenital amegakaryocytic thrombocytopenia (CAMT)
6 Active Policies
ANTHEM-MP-A047560 — TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
ANTHEM-MP-A070096 — TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
ANTHEM-MP-A053844 — TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
ANTHEM-MP-A053842 — TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
Related Codes
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