Donor Lymphocyte Infusion

DLI is medically necessary for patients with a prior medically necessary allogeneic bone marrow or peripheral stem cell transplant for specified leukemias (ALL C91.00–C91.02, AML C92.00–C92.02, and BCR/ABL‑positive CML C92.10–C92.12) when selection criteria are met and transplant status (Z94.81 or Z94.84) is documented. DLI is not covered (experimental/investigational) for multiple myeloma, G‑CSF–stimulated DLI, intrathecal DLI, any modified donor lymphocytes (e.g., ex‑vivo expansion, antigen‑specific T‑cell lines, T‑cell depletion, CAR or other genetic modifications), or pre‑transplant ECP‑treated donor lymphocytes for solid organ graft prevention.

"ICD-10 codes covered if selection criteria are met: Z94."

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