S2666
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Chronic granulomatous disease
- Allogeneic (ablative and non-myeloablative) hematopoietic stem cell transplantationis consideredmedically necessaryfor individuals with the following disorders. In addition, individuals with Sickle Cell Disease or Thalassemia should meet the Disease Specific Criteria below.
- Bone Marrow Failure SyndromesAcquired aplastic anemia (drug, idiopathic, immune disorder, toxin or viral infection)Heritable bone marrow syndromes:Congenital amegakaryocytic thrombocytopenia (CAMT)Diamond-Blackfan anemia (DBA)Dyskeratosis congenitaFanconiâs anemia (FA)Schwachman-Diamond syndrome (SDS)Paroxysmal nocturnal hemoglobinuria (PNH)
- Acquired aplastic anemia (drug, idiopathic, immune disorder, toxin or viral infection)
- Heritable bone marrow syndromes:Congenital amegakaryocytic thrombocytopenia (CAMT)Diamond-Blackfan anemia (DBA)Dyskeratosis congenitaFanconiâs anemia (FA)Schwachman-Diamond syndrome (SDS)
- Congenital amegakaryocytic thrombocytopenia (CAMT)
2 Active Policies
ANTHEM-MP-A047560 — TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
ANTHEM-MED.00147 — MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.