White Cell Colony Stimulating Factors
L37176
This LCD covers G‑CSFs (filgrastim, pegfilgrastim, tbo‑filgrastim) and GM‑CSF (sargramostim) for specific indications (chemo‑induced neutropenia prophylaxis/treatment, AML induction/consolidation support, stem‑cell mobilization—except pegfilgrastim—post‑transplant myeloid recovery, and certain radiation/ARS indications) and excludes uses not meeting criteria (including pegfilgrastim for mobilization and self/caregiver‑administered G/GM‑CSFs which are not payable). Key requirements: medical record must document ANC, the cytotoxic agent, administration times and medical necessity; pegfilgrastim is generally given ≥24 hours after chemo unless a documented exception; primary prophylaxis is reserved for regimens with FN risk ≥20% (or 10–20% with ≥1 risk factor), secondary prophylaxis only after documented FN, and continued use is not supported if no response within 28–42 days.
" - Adult AML shortly after completion of induction or repeat induction chemotherapy, or after consolidation chemotherapy for AML."