S2142, Cord blood-derived stem-cell transplantation, allogeneic
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Documentation Required
- ChronOS / TCP with bone marrow studies: documentation of diagnosis (benign cystic bone lesion type: non-ossifying fibroma, enchondroma, fibrous dysplasia, aneurysmal bone cyst, juvenile bone cyst), operative records showing mixing of ChronOS granules with autologous bone marrow harvested during surgery, and radiographic follow-up using Neer classification for bone regeneration.
- For antibiotic bead local therapy (calcium sulfate beads): operative notes documenting debridement and bead placement, systemic antibiotic regimen, culture results, and follow-up documentation of wound status (presence/character of wound discharge) and radiographic dissolution of beads (authors reported beads dissolved at average ~36 days).
- For INFUSE lumbar fusion: documentation that 'The member meets medical necessity criteria for lumbar spinal fusion in CPB 0743 - Spinal Surgery: Laminectomy and Fusion' and that 'INFUSE Bone Graft is to be implanted via an anterior (ALIF) or lateral (OLIF, DLIF, XLIF or LLIF) approach.'
- For INFUSE in tibial shaft fractures: documentation that the patient is skeletally mature; that the acute, open tibial shaft fracture has been stabilized with intramedullary nail fixation; that appropriate wound management was performed; and that INFUSE Bone Graft will be applied within 14 days after the initial fracture.
- For PMMA or calcium sulfate antibiotic beads: documentation of diagnosis of chronic osteomyelitis (e.g., ICD-10 M86.30–M86.69) and documentation that beads will be used in conjunction with intravenous antibiotics.
- For allograft use in spinal fusion and osteochondral defects: documentation that clinical indication meets the selection criteria for spinal fusion per CPB 0743 (reference to CPB 0743 required) or documentation of osteochondral defect requiring bone void filler.
Key Coverage Criteria
- posterolateral lumbar fusion
- cervical interbody fusion
- fracture healing / nonunion fractures
- long bone nonunion (tibial nonunions referenced)
- treatment of open tibial fractures
- healing nonunion fractures
20 Active Policies
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
ANTHEM-MP-A047473, TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
ANTHEM-MP-A045963, Status
AETNA-CPB-0411, Bone and Tendon Graft Substitutes and Adjuncts
AETNA-CPB-0394, Epilepsy Surgery
AETNA-CPB-0190, Stem Cells for Hematopoietic Cell Transplant
AETNA-CPB-0602, Intradiscal Procedures
AMBETTER-CP.MP.141, Nonmyeloablative Allogeneic Stem Cell Transplants
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-SUR703.043, Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
ANTHEM-MP-A047560, TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
Related Codes
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