S0091 — Granisetron hydrochloride, 1 mg (for circumstances falling under the medicare statute, use q0166)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Key Coverage Criteria
- A single administration of allogeneic processed thymus tissue is consideredmedically necessaryfor immune reconstitution in the pediatric population* with congenital athymia whenallof the following criteria are met:
- Congenital athymia is confirmed via flow cytometry as less than 50 naïve T cells/mm3in the peripheral blood or less than 5% of total T cells being naïve in phenotype;and
- Documentation that infection control measures, including immunoprophylaxis, can reasonably be maintained until the development of thymic function is established;and
- Absence of comorbidities, in the opinion of the treating clinician, that are reasonably likely to result in severe complications, including death from administration of allogeneic processed thymus tissue (for example, pre-existing renal impairment, or cytomegalovirus or Epstein-Barr virus infection).
- *Note:Pediatric population (generally age below 18 years of age)
1 Active Policy
ANTHEM-MP-E001585 — TRANS.00038 Thymus Tissue Transplantation
Related Codes
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