J2505, Injection, pegfilgrastim, 6 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of a prior, medically necessary allogeneic bone marrow transplantation or peripheral stem cell transplantation (e.g., transplant operative report, discharge summary, transplant center records).
- Clinical documentation supporting the indication for DLI (diagnosis/problem list with corresponding ICD-10 code among covered diagnoses such as C91.00-C91.02, C92.00-C92.02, C92.10-C92.12, or documentation of transplant status Z94.81 / Z94.84).
- Medical records demonstrating that the requested DLI is not one of the policy-listed experimental/investigational uses (e.g., not CAR-modified donor lymphocytes, not G-CSF-stimulated DLI for the purpose stated, not intrathecal DLI, not ECP-treated donor cells for pre-transplant organ tolerance, etc.).
- If applicable, documentation of prior treatments and rationale for DLI as salvage therapy or for graft-versus-leukemia effects (e.g., prior relapse after allo-HCT, prior therapies tried and outcomes).
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: Z94.84 (Stem cells transplant status).
- ICD-10 codes covered if selection criteria are met: C92.10 - C92.12 (Chronic myeloid leukemia, BCR/ABL-positive).
- ICD-10 codes covered if selection criteria are met: Z94.81 (Bone marrow transplant status).
- Donor lymphocyte infusion (DLI) is considered medically necessary for persons who have a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation.
- DLI for treatment/management related to the following covered ICD-10 diagnoses when selection criteria are met: C91.00 - C91.02 (Acute lymphoblastic leukemia [ALL]).
- DLI for treatment/management related to the following covered ICD-10 diagnoses when selection criteria are met: C92.00 - C92.02 (Acute myeloblastic leukemia).
2 Active Policies
AETNA-CPB-0638, Donor Lymphocyte Infusion
CARELON-febrile-neutropenia-risk, Febrile Neutropenia Risk
Related Codes
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