TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation

This policy addresses umbilical cord blood progenitor cell collection, storage, and transplantation for hematopoietic stem cell transplant. Coverage is medically necessary when one or two donor cord units are used for a single recipient, the total nucleated cell dose is ≥2.3 × 10^7/kg, and the unit(s) is used for an allogeneic transplant for an approved indication with standard transplant criteria met; collection/storage is covered only when an allogeneic transplant is imminent for an identified recipient and these criteria are satisfied. It is not covered (investigational) when these criteria are not met or for prophylactic collection/storage for unspecified future use, including autologous use by the original donor or unspecified future allogeneic use in related or unrelated recipients.

"The use of umbilical cord blood progenitor cell transplantation is consideredmedically necessaryfor selected individuals whenallof the following criteria are met:One or two donor cord unit(s) is us..."