J3402, Injection, remestemcel-l-rknd, per therapeutic dose
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Inferred documentation items that would support medical necessity: documentation that the patient's own stem cells have been destroyed by disease or by intensive treatment (e.g., records of high‑dose chemotherapy and/or radiation); documentation of donor identity (related or unrelated) and donor selection; records of the infusion procedure and subsequent engraftment (e.g., blood counts, marrow reports); documentation of immunosuppressive therapy given prior to transplantation.
- Not specified in this excerpt. (Implied requirement: documentation sufficient to demonstrate Medicare-level medical necessity may be required, but no explicit document list or examples are provided.)
- Corporate Transplant Department contact information: Phone: 1-866-421-5663; Fax: 502-508-9300; Email: transplant@humana.com
Key Coverage Criteria
- Individual is 2 months to 17 years of age ${ }^{5,11}$; AND
- Recurrence of GVHD after CR — Repeat administration of Ryoncil twice a week for an additional 4
- Transplantation of stem cells from healthy donors to an individual whose own stem cells have been destroyed by disease.
- Transplantation of stem cells from healthy donors to an individual whose own stem cells have been destroyed by intensive treatments (e.g., high-dose chemotherapy and/or radiation therapy).
- Use of donor stem cells from either a related or unrelated donor for engraftment (produced blood cells) following infusion into the recipient's bloodstream.
- Treatment for acute graft-versus-host disease (aGVHD) — treatment decisions are based on the specific organs involved, the severity (or grade) of the disease and whether the GI tract is affected.
13 Active Policies
ARKBLUE-REMESTEMCEL-L-RKND-E-G-RYONCIL-43E2C2ED2A, Remestemcel-L-rknd (e.g., Ryoncil)
AR
FLORIDA_BLUE-FLBLUE-RYONCIL-REMESTEMCEL-L-RKND-93627B2C70, Ryoncil (remestemcel-L-rknd)
FL
BCIDAHO-05-01-674-E654A87AEA, Ryoncil (remestemcel-L). Medical Policy MP 5.01.674 Ryoncil (remestemcel-L) DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general guidance for applying Blue Cross of Idaho benefit
ID
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