S2140, Cord blood harvesting for transplantation, allogeneic
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- When Omisirge (omidubicel) is requested: documentation meeting the clinical criteria specified in CPB 1032 - Omidubicel‑only (Omisirge).
- Documentation that an allogeneic bone marrow or peripheral stem cell transplant has been authorized/approved by Aetna (authorization/medical necessity for the transplant).
- Documentation of donor relationship demonstrating first‑ or second‑degree family member status when coverage is requested for compatibility testing, harvesting, or short‑term storage of donor cells.
- HLA typing and compatibility testing results (examples: HLA typing codes 86813, 86817; mixed lymphocyte culture 86821; compatibility tests 86920–86923) when compatibility testing or donor identification services are performed.
- For short‑term cord blood storage coverage: documentation of the recipient/member diagnosis of malignancy and evidence a match exists between stored cord blood and potential recipient.
- For stem cell boosting (HPC boost): documentation of graft failure or poor graft function following an approved allogeneic HSCT (clinical evidence such as transfusion‑dependent platelet counts, leukopenia, transfusion‑dependent anemia, or other treating physician documentation supporting need for boost).
Key Coverage Criteria
- Compatibility testing of prospective donors who are close family members (first-degree relatives i.e., parents, siblings and children, or second-degree relatives i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling) and harvesting and short-term storage of peripheral stem cells or bone marrow from the identified donor when an allogeneic bone marrow or peripheral stem cell transplant is authorized by Aetna.
- Umbilical cord blood stem cells considered an acceptable alternative to conventional bone marrow or peripheral stem cells for allogeneic transplant.
- Short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment when there is a match.
- Stem cell boosting in the setting of graft failure following an approved allogeneic hematopoietic stem cell transplant (HPC boost).
- Omidubicel‑only (Omisirge) when clinical criteria are met (see CPB 1032 - Omidubicel‑only (Omisirge)).
- When a covered family member of a newborn infant has a medically necessary indication for an allogeneic bone marrow transplant and wishes to use umbilical cord blood stem cells as an alternative, Aetna covers testing of umbilical cord blood for compatibility for transplant under the potential recipient’s plan.
20 Active Policies
UHC-POL-umbilical-cord-blood-harvesting-and-storage-future-use, Umbilical Cord Blood Harvesting and Storage for Future Use
AETNA-CPB-0190, Stem Cells for Hematopoietic Cell Transplant
SUR703.058, Collection and Storage of Umbilical Cord Blood Stem Cells
SUR703.043, Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
SUR703.038, Hematopoietic Cell Transplantation for Breast Cancer
SUR703.029, Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
SUR703.041, Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
SUR703.034, Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
SUR703.033, Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
SUR703.046, Hematopoietic Cell Transplantation for Primary Systemic Amyloidosis
SUR703.050, Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia
BCBSIL-SUR703.058, Collection and Storage of Umbilical Cord Blood Stem Cells
BCBSIL-SUR703.043, Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
BCBSIL-SUR703.037, Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
BCBSIL-SUR703.038, Hematopoietic Cell Transplantation for Breast Cancer
BCBSIL-SUR703.029, Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
BCBSIL-SUR703.041, Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
BCBSIL-SUR703.034, Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
BCBSIL-SUR703.033, Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
ANTHEM-MP-A045960, TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
Related Codes
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