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L.8.01.412
A number of inherited and acquired conditions have the potential for severe and/or progressive disease. For some conditions, allogeneic hematopoietic cell transplantation (allo-HCT) has been used to alter the natural history of the disease or potentially offer a cure.
Genetic Diseases and Acquired Anemias
HemoglobinopathiesThalassemias result from variants in the globin genes, resulting in reduced or absent hemoglobin production, thereby reducing oxygen delivery. The supportive treatment of beta-thalassemia major requires life-long red blood cell transfusions that lead to progressive iron overload and the potential for organ damage and impaired cardiac, hepatic, and endocrine function. Sickle cell disease is caused by a single amino acid substitution in the beta chain of hemoglobin, and, unlike thalassemia major, has a variable course of clinical severity. Sickle cell disease typically manifests clinically with anemia, severe painful crises, acute chest syndrome, stroke, chronic pulmonary and renal dysfunction, growth retardation, neurologic deficits, and premature death. The mean age of death for patients with sickle cell disease has been demonstrated as 42 years for men and 48 for women.
TreatmentThe only definitive cure for thalassemia is to correct the genetic defect with allogeneic hematopoietic cell transplantation (allo-HCT).
Three major therapeutic options are available for sickle cell disease: chronic blood transfusions, hydroxyurea, and allo-HCT, the latter being the only possibility for cure.
Bone Marrow Failure SyndromesAplastic anemia in children is rare and is most often idiopathic and less commonly, due to a hereditary disorder. Inherited syndromes include Fanconi anemia, a rare, autosomal recessive disease, characterized by genomic instability, with congenital abnormalities, chromosome breakage, cancer susceptibility, and progressive bone marrow failure leading to pancytopenia and severe aplastic anemia. Frequently, this disease terminates in myelodysplastic syndrome or acute myeloid leukemia. Most patients with Fanconi anemia succumb to the complications of severe aplastic anemia, leukemia, or solid tumors, with a median survival of 30 years of age.
Dyskeratosis congenita is characterized by marked telomere dysregulation with clinical features of reticulated skin hyperpigmentation, nail dystrophy, and oral leukoplakia. Early mortality is associated with bone marrow failure, infections, pulmonary complications, or malignancy.
Variants affecting ribosome assembly and function are associated with Shwachman-Diamond syndrome and Diamond-Blackfan syndrome. Shwachman-Diamond has clinical features that include pancreatic exocrine insufficiency, skeletal abnormalities, and cytopenias, with some patients developing aplastic anemia. As with other bone marrow failure syndromes, patients are at increased risk of myelodysplastic syndrome and malignant transformation, especially acute myeloid leukemia. Diamond-Blackfan anemia is characterized by absent or decreased erythroid precursors in the bone marrow, with 30% of patients also having a variety of physical anomalies.
TreatmentIn Fanconi anemia, HCT is currently the only treatment that definitively restores normal hematopoiesis. Excellent results have been observed with the use of HLA-matched sibling allo-HCT, with cure of the marrow failure and amelioration of the risk of leukemia.
Primary ImmunodeficienciesThe primary immunodeficiencies are a genetically heterogeneous group of diseases that affect distinct components of the immune system. More than 120 gene defects have been described, causing more than 150 disease phenotypes. The most severe defects (collectively known as severe combined immunodeficiency) cause an absence or dysfunction of T lymphocytes and sometimes B lymphocytes and natural killer cells.
TreatmentWithout treatment, patients with severe combined immunodeficiency usually die by 12 to 18 months of age. With supportive care, including prophylactic medication, the lifespan of these patients can be prolonged, but long-term outlook is still poor, with many dying from infectious or inflammatory complications or malignancy by early adulthood. Bone marrow transplantation is the only definitive cure, and the treatment of choice for severe combined immunodeficiency and other primary immunodeficiencies, including Wiskott-Aldrich syndrome and congenital defects of neutrophil function.
Inherited Metabolic DiseasesLysosomal storage disorders consist of many different rare diseases caused by a single gene defect, and most are inherited as an autosomal recessive trait. Lysosomal storage disorders are caused by specific enzyme deficiencies that result in defective lysosomal acid hydrolysis of endogenous macromolecules that subsequently accumulate as a toxic substance. Peroxisomal storage disorders arise due to a defect in a membrane transporter protein that leads to defects in the metabolism of long-chain fatty acids. Lysosomal storage disorders and peroxisomal storage disorders affect multiple organ systems, including the central and peripheral nervous systems. These disorders are progressive and often fatal in childhood due to both the accumulation of toxic substrate and a deficiency of the product of the enzyme reaction. Hurler syndrome usually leads to premature death by 5 years of age.
TreatmentExogenous enzyme replacement therapy is available for a limited number of the inherited metabolic diseases; however, these drugs do not cross the blood-brain barrier, which results in ineffective treatment of the central nervous system. Stem cell transplantation provides a constant source of enzyme replacement from the engrafted donor cells, which are not impeded by the blood-brain barrier. The donor-derived cells can migrate and engraft in many organ systems, giving rise to different types of cells, (eg, microglial cells in the brain and Kupffer cells in the liver).
Allogeneic HCT has been primarily used to treat the inherited metabolic diseases that belong to the lysosomal and peroxisomal storage disorders, as listed in the table below. The first stem cell transplant for an inherited metabolic disease was performed in 1980 in a patient with Hurler syndrome. Since that time, more than 1,000 transplants have been performed worldwide.
Lysosomal and Peroxisomal Storage Disorders
Category | Diagnosis | Other Names |
Mucopolysaccharidosis | Mucopolysaccharidosis I H or H/SMucopolysaccharidosis IIMucopolysaccharidosis III A-DMucopolysaccharidosis IV A-BMucopolysaccharidosis VIMucopolysaccharidosis VII | Hurler syndrome or Hurler-Scheie syndromeHunter syndromeSanfilippo syndrome A-DMorquio syndrome A-BMaroteaux-Lamy syndromeSly syndrome |
Sphingolipiodsis | Fabry diseaseFarber diseaseGaucher disease types 1 and 3 GM1 gangliosidosisNiemann-Pick disease A and BTay-Sachs diseaseSandhoff diseaseGloboid cell leukodystrophyMetachromatic leukodystrophy | Lipogranulomatosis Krabbe diseaseMLD |
Glycoproteinosis | AspartylglucosaminuriaFucosidosisAlpha-MannosidosisBeta-MannosidosisMucolipidosis III and IV | Sialidosis |
Other lipidoses | Niemann-Pick disease CWolman diseaseCeroid lipofuscinosis type III | Batten disease |
Glycogen storage | Glycogen storage disease type II | Pompe disease |
Multiple enzyme deficiency | GalactosialidosisMucolipidosis type II | I-cell disease |
Lysosomal transport defects | CystinosisSialic acid storage diseaseSalla disease | |
Peroxisomal storage disorders | AdrenoleukodystrophyAdrenomyeloneuropathy | ALDAMN |
Genetic Disorders Affecting Skeletal Tissue
Osteopetrosis is a condition caused by defects in osteoclast development and/or function. The osteoclast (the cell that functions in the breakdown and resorption of bone tissue) is known to be part of the hematopoietic family and shares a common progenitor with the macrophage in the bone marrow. Osteopetrosis is a heterogeneous group of heritable disorders, resulting in several different types of variable severity. The most severely affected patients are those with infantile malignant osteopetrosis (Albers-Schonberg disease or marble bone disease). Patients with infantile malignant osteopetrosis suffer from dense bone, including a heavy head with frontal bossing, exophthalmos, blindness by approximately 6 months of age, and severe hematologic malfunction with bone marrow failure. Seventy percent of these patients die before the age of 6 years, often of recurrent infections.
TreatmentHCT is the only curative therapy for this fatal disease.
Hematopoietic Cell Transplantation
Hematopoietic cell transplantation (HCT) is a procedure in which hematopoietic stem cells are intravenously infused to restore bone marrow and immune function in cancer patients who receive bone marrow-toxic doses of cytotoxic drugs with or without whole-body radiotherapy. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HCT) or a donor (allo-HCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates. Cord blood transplantation is discussed in a separate policy, Placental and Umbilical Cord Blood as a Source of Stem Cells .
Immunologic compatibility between infused hematopoietic stem cells and the recipient is not an issue in autologous HCT. In allogeneic stem cell transplantation, immunologic compatibility between donor and patient is a critical factor in achieving a successful outcome. Compatibility is established by typing of human leukocyte antigen (HLA) using cellular, serologic, or molecular techniques. HLA refers to the gene complex expressed at the HLA-A, -B, and -DR (antigen-D related) loci on each arm of chromosome 6. An acceptable donor will match the patient at all or most of the HLA loci.
Conditioning for Hematopoietic Cell Transplantation
Conventional Conditioning
The conventional ("classical") practice of allo-HCT involves administration of cytotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to cause bone marrow ablation in the recipient. The beneficial treatment effect of this procedure is due to a combination of the initial eradication of malignant cells and subsequent graft-versus-malignancy effect mediated by non-self-immunologic effector cells. While the slower graft-versus-malignancy effect is considered the potentially curative component, it may be overwhelmed by existing disease in the absence of pretransplant conditioning. Intense conditioning regimens are limited to patients who are sufficiently medically fit to tolerate substantial adverse effects. These include opportunistic infections secondary to loss of endogenous bone marrow function and organ damage or failure caused by cytotoxic drugs. Subsequent to graft infusion in allo-HCT immunosuppressant drugs are required to minimize graft rejection and graft-versus-host disease, which increases susceptibility to opportunistic infections.
The success of autologous HCT is predicated on the potential of cytotoxic chemotherapy, with or without radiotherapy, to eradicate cancerous cells from the blood and bone marrow. This permits subsequent engraftment and repopulation of the bone marrow with presumably normal hematopoietic stem cells obtained from the patient before undergoing bone marrow ablation. Therefore, autologous HCT is typically performed as consolidation therapy when the patient’s disease is in complete remission. Patients who undergo autologous HCT are also susceptible to chemotherapy-related toxicities and opportunistic infections before engraftment, but not GVH disease.
Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation
Reduced-intensity conditioning refers to the pretransplant use of lower doses of cytotoxic drugs or less intense regimens of radiotherapy than are used in traditional full-dose myeloablative conditioning treatments. Although the definition of reduced-intensity conditioning is variable, with numerous versions employed, all regimens seek to balance the competing effects of relapse due to residual disease and non-relapse mortality. The goal of reduced-intensity conditioning is to reduce disease burden and to minimize associated treatment-related morbidity and non-relapse mortality in the period during which the beneficial graft-versus-malignancy effect of allogeneic transplantation develops. Reduced-intensity conditioning regimens range from nearly total myeloablative to minimally myeloablative with lymphoablation, with intensity tailored to specific diseases and patient condition. Patients who undergo reduced-intensity conditioning with allo-HCT initially demonstrate donor cell engraftment and bone marrow mixed chimerism. Most will subsequently convert to full-donor chimerism. In this policy, the term reduced-intensity conditioning will refer to all conditioning regimens intended to be nonmyeloablative.
HCT for autoimmune disease, such as rheumatoid arthritis or multiple sclerosis, is considered separately in the Hematopoietic Cell Transplantation for Autoimmune Diseases medical policy.
The U.S. Food and Drug Administration regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under the Code of Federal Regulation, Title 21, parts 1270 and 1271. Hematopoietic stem cells are included in these regulations.
No benefits will be provided for a covered transplant procedure or a transplant evaluation unless the Member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
Allogeneic hematopoietic cell transplantation is considered medically necessary for select patients with the following disorders:
Hemoglobinopathies
Sickle cell anemia for children or young adults with either a history of prior stroke or at increased risk of stroke or end-organ damage.
Homozygous beta-thalassemia (i.e., thalassemia major).
Bone Marrow Failure Syndromes
Aplastic anemia including hereditary (including Fanconi anemia, dyskeratosis congenita, Shwachman-Diamond syndrome, Diamond-Blackfan syndrome) or acquired (e.g., secondary to drug or toxin exposure) forms.
Primary Immunodeficiencies
Absent or defective T-cell function (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, X-linked lymphoproliferative syndrome)
Absent or defective natural killer function (e.g. Chediak-Higashi syndrome)
Absent or defective neutrophil function (e.g. Kostmann syndrome, chronic granulomatous disease, leukocyte adhesion defect).
(See Guideline 1.)
Inherited Metabolic Disease
Lysosomal and peroxisomal storage disorders except Hunter, Sanfilippo, and Morquio syndromes.
(See Guideline 2.)
Genetic Disorders Affecting Skeletal Tissue
Infantile malignant osteopetrosis (Albers-Schonberg disease or marble bone disease).
For Federal Employee Program (FEP) subscribers, the Service Benefit Plan includes specific conditions in which autologous or allogeneic blood or marrow stem cell transplants would be considered eligible for coverage.
For State and School Employee subscribers, all bone marrow/stem cell transplants must be certified as medically necessary by the Plan’s Utilization Review Vendor. No benefits will be provided for any transplant procedure unless prior approval for the transplant is obtained.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Guideline 1
The following guideline lists immunodeficiencies that have been successfully treated by allogeneic hematopoietic cell transplantation (allo-HCT).
Lymphocyte Immunodeficiencies
Adenosine deaminase deficiency
Artemis deficiency
Calcium channel deficiency
CD40 ligand deficiency
Cernunnos/X-linked lymphoproliferative disease deficiency
CHARGE syndrome with immune deficiency
Common gamma chain deficiency
Deficiencies in CD45, CD3, CD8
DiGeorge syndrome
DNA ligase IV deficiency syndrome
Interleukin-7 receptor alpha deficiency
Janus-associated kinase 3 deficiency
Major histocompatibility class II deficiency
Omenn syndrome
Purine nucleoside phosphorylase deficiency
Recombinase-activating gene 1/2 deficiency
Reticular dysgenesis
Winged helix deficiency
Wiskott-Aldrich syndrome
X-linked lymphoproliferative disease
Zeta-chain-associated protein-70 deficiency
Phagocytic Deficiencies
Chédiak-Higashi syndrome
Chronic granulomatous disease
Griscelli syndrome type 2
Hemophagocytic lymphohistiocytosis
Interferon-gamma receptor deficiencies
Leukocyte adhesion deficiency
Severe congenital neutropenias
Shwachman-Diamond syndrome
Other Immunodeficiencies
Autoimmune lymphoproliferative syndrome
Cartilage hair hypoplasia
CD25 deficiency
Hyper IgD and IgE syndromes
Immunodeficiency, centromeric instability, and facial dysmorphism syndrome
Immunodysregulation polyendocrinopathy enteropathy X-linked syndrome
Nuclear factor-κ B (NF -κB) essential modulator deficiency
NF-κB inhibitor, NF -κB-alpha deficiency
Nijmegen breakage syndrome
Guideline 2
For inherited metabolic disorders, allo-HCT has been proven effective in some cases of Hurler, Maroteaux-Lamy, and Sly syndromes, childhood onset cerebral X-linked adrenoleukodystrophy, globoid cell leukodystrophy, metachromatic leukodystrophy, alpha-mannosidosis, and aspartylglucosaminuria. Allogeneic HCT is possibly effective for fucosidosis, Gaucher types 1 and 3, Farber lipogranulomatosis, galactosialidosis, GM1 gangliosidosis, mucolipidosis II (I-cell disease), multiple sulfatase deficiency, Niemann-Pick disease, neuronal ceroid lipofuscinosis, sialidosis, and Wolman disease. Allogeneic HCT has not been effective in Hunter, Sanfilippo, or Morquio syndromes.
The experience with reduced-intensity conditioning and allo-HCT for the diseases listed in this policy has been limited to small numbers of patients and has yielded mixed results, depending on the disease category. In general, the results have been most promising in the bone marrow failure syndromes and primary immunodeficiencies. In the hemoglobinopathies, success has been hampered by difficulties with high rates of graft rejection, and in adults, severe graft-versus-host-disease. Phase 2/3 trials are ongoing or completed examining the role of this type of transplant for these diseases, as outlined in the Ongoing and Unpublished Clinical Trials.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22.
8/19/2004: Code Reference section completed.
11/18/2004: Reviewed by MPAC; no changes.
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted.
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy.
09/12/2006: Coding updated. ICD9 2006 revisions added to policy.
12/21/2006: Policy reviewed, no changes.
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy.
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions.
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007.
06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. Table inserted describing Lysosomal and Peroxisomal Storage Disorders. Policy statement section revised to include medically necessary indications for allogeneic hematopoietic stem cell transplantation. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Covered Codes Table.
10/21/2010: Policy reviewed; no changes.
10/05/2011: Policy reviewed; no changes.
11/30/2012: Policy reviewed; no changes.
11/15/2013: Policy reviewed; no changes.
11/13/2014: Policy reviewed; description updated regarding bone marrow failure syndromes. Policy statement regarding bone marrow failure syndromes updated to include aplastic anemia.
08/21/2015: Code Reference section update to add ICD-10 codes. Revised the descriptions for CPT codes 38240 and 38242; removed deleted CPT code G0363; removed deleted code CPT 96445 and replaced with CPT code 96446. Removed ICD-9 procedure code 99.25 and ICD-9 diagnosis code 288.0.
06/09/2016: Policy number A.8.01.22 added. Policy description updated regarding FDA regulations. Medically necessary policy statement updated to change "allogeneic bone marrow transplants" to "allogeneic hematopoietic stem cell transplantation." Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition.
09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2.
11/08/2017: Policy updated to change "hematopoietic stem-cell transplantation" to "hematopoietic cell transplantation" throughout the policy. Policy description updated regarding lysosomal and peroxisomal storage disorders. Medically necessary statement on bone marrow failures updated to add "syndrome." Policy Guidelines updated. Removed the following ICD-9 procedure codes: 41.02, 41.03, 41.05 and 41.08. Removed deleted ICD-10 procedure codes 30233G1, 30243G1, 30233Y1, and 30243Y1.
12/21/2017: Code Reference section updated to add new 2018 CPT code 38222. Revised descriptions for CPT codes 38220 and 38221 effective 01/01/2018.
02/12/2018: Policy description updated. Policy statements unchanged.
03/11/2019: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted CPT code 86822 and HCPCS code G0364.
09/27/2019: Code Reference section updated to add new ICD-10 procedure codes 30233U2, 30243U2, 30233U3, 30243U3, 30233U4, and 30243U4, effective 10/01/2019.
02/21/2020: Policy description updated regarding hematopoietic cell transplantation (HCT) and conditioning for HCT. Policy statements unchanged.
09/24/2020: Code Reference section updated to add new ICD-10 diagnosis codes D57.413, D57.418, D57.42, D57.431, D57.432, D57.433, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.458, D57.459, D57.03, D57.09, D57.213, D57.218, D57.813, and D57.818, effective 10/01/2020.
04/01/2021: Policy description updated. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
10/01/2021: Code Reference section updated to add new ICD-10 diagnosis code E75.244 effective 10/01/2021.
12/27/2021: Code Reference section updated to make note of deleted ICD-10 procedure codes.
09/30/2022: Code Reference section updated to revise code description for ICD-10 diagnosis code C94.6. Added new ICD-10 diagnosis code D81.82, effective 10/01/2022.
12/21/2023: Code Reference section updated to revise the code description for CPT code 96446, effective 01/01/2024.
02/14/2024: Medical policy number changed from "A.8.01.22" to "L.8.01.412." Policy reviewed. Policy statements unchanged.
10/01/2024: Code Reference section updated to add new ICD-10 diagnosis code D61.03.
03/27/2025: Policy reviewed; no changes.
Blue Cross Blue Shield Association policy # 8.01.22
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Code Number | Description | ||
CPT-4 | |||
38204 | Management of recipient hematopoietic progenitor cell donor search and cell acquisition | ||
38205 | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic | ||
38207 | Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage | ||
38208 | Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing | ||
38209 | Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing | ||
38210 | Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion | ||
38211 | Transplant preparation of hematopoietic progenitor cells; tumor cell depletion | ||
38212 | Transplant preparation of hematopoietic progenitor cells; red blood cell removal | ||
38213 | Transplant preparation of hematopoietic progenitor cells; platelet depletion | ||
38214 | Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion | ||
38215 | Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer | ||
38220 | Diagnostic bone marrow; aspiration(s) | ||
38221 | Bone marrow; biopsy(ies) | ||
38222 | Diagnostic bone marrow; biopsy(ies) and aspiration(s) | ||
38230 | Bone marrow harvesting for transplantation | ||
38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor) | ||
38242 | Allogeneic lymphocyte infusions | ||
86812 | HLA typing; A, B, or C (eg, A10, B7, B27), single antigen | ||
86813 | HLA typing; A, B, or C, multiple antigens | ||
86816 | HLA typing; DR/DQ, single antigen | ||
86817 | HLA typing; DR/DQ, multiple antigens | ||
86821 | HLA typing; lymphocyte culture, mixed (MLC) | ||
86825 | HLA crossmatch, non-cytotoxic (eg. using flow cytometry); first serum sample or dilution | ||
86826 | HLA crossmatch, non-cytotoxic (eg. using flow cytometry); each additional serum sample or serum solution | ||
96401 | Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic | ||
96402 | Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic | ||
96405 | Chemotherapy administration; intralesional, up to and including 7 lesions | ||
96406 | Chemotherapy administration; intralesional, more than 7 lesions | ||
96409 | Chemotherapy administration; intravenous, push technique, single or initial substance/drug | ||
96411 | Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) | ||
96413 | Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug | ||
96415 | Chemotherapy administration, intravenous infusion technique; each additional hour, 1 to 8 hours, (List separately in addition to code for primary procedure) | ||
96416 | Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump | ||
96417 | Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure) | ||
96420 | Chemotherapy administration, intra-arterial; push technique | ||
96422 | Chemotherapy administration, intra-arterial; infusion technique, up to one hour | ||
96423 | Chemotherapy administration, intra-arterial; infusion technique, each additional hour up to 8 hours (List separately in addition to code for primary procedure) | ||
96425 | Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump | ||
96440 | Chemotherapy administration into pleural cavity, requiring and including thoracentesis | ||
96446 | Chemotherapy administration into the peritoneal cavity via implanted port or catheter | ||
96450 | Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture | ||
96521 | Refilling and maintenance of portable pump | ||
96522 | Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) | ||
96523 | Irrigation of implanted venous access device for drug delivery systems | ||
HCPCS - To report antineoplastic drugs, see code range J9000-J9999 in the HCPCS Level II manual. | |||
Q0083 | Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit | ||
Q0084 | Chemotherapy administration by infusion technique only, per visit | ||
Q0085 | Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit | ||
S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including pheresis and cell preparation/storage; marrow ablative therapy; drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition | ||
ICD-9 Procedure | ICD-10 Procedure | ||
30233G2, 30243G2 | Transfusion of allogeneic related bone marrow into vein (peripheral or central), percutaneous approach | ||
30233G3, 30243G3 | Transfusion of allogeneic unrelated bone marrow into vein (peripheral or central), percutaneous approach | ||
30233G4, 30243G4 | Transfusion of allogeneic unspecified bone marrow into vein (peripheral or central), percutaneous approach | ||
30233U2, 30243U2 | Transfusion of allogeneic related T-cell depleted hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233U3, 30243U3 | Transfusion of allogeneic unrelated T-cell depleted hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233U4, 30243U4 | Transfusion of allogeneic unspecified T-cell depleted hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233Y2, 30243Y2 | Transfusion of allogeneic related hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233Y3, 30243Y3 | Transfusion of allogeneic unrelated hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233Y4, 30243Y4 | Transfusion of allogeneic unspecified hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
41.91 | Aspiration of bone marrow from donor for transplant | 079T30Z | Drainage of bone marrow with drainage device, percutaneous approach |
079T3ZZ | Drainage of bone marrow, percutaneous approach | ||
07DQ3ZZ | Extraction of sternum bone marrow, percutaneous approach | ||
07DR3ZZ | Extraction of iliac bone marrow, percutaneous approach | ||
07DS3ZZ | Extraction of vertebral bone marrow, percutaneous approach | ||
99.79 | Other apheresis (harvest) of stem cells | 6A550ZT, 6A551ZT | Pheresis of cord blood stems, single or multiple |
6A550ZV, 6A551ZV | Pheresis of hematopoietic stems, single or multiple | ||
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
238.71 | Essential thrombocythemia | D47.3 | Essential (hemorrhagic) thrombocythemia |
238.72 | Low grade myelodysplastic syndrome lesions | D46.0, D46.1, D46.20, D46.21, D46.4, D46.A, D46.B | Myelodysplastic syndromes |
238.73 | High grade myelodysplastic syndrome lesions | D46.22 | Refractory anemia with excess of blasts 2 |
238.74 | Myelodysplastic syndrome with 5q deletion | D46.C | Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality |
238.75 | Myelodysplastic syndrome, unspecified | D46.9, D46.Z | Other and unspecified myelodysplastic syndromes |
238.76 | Myelofibrosis with myeloid metaplasia | D47.1 | Chronic myeloproliferative disease |
D47.Z2 | Castleman disease | ||
238.79 | Other lymphatic and hematopoietic tissues | C88.8 | Other malignant immunoproliferative diseases |
C94.40 - C94.42 | Acute panmyelosis (code range) | ||
C94.6 | Myelodysplastic disease, not elsewhere classified | ||
D47.1, D47.9, D47.Z9 | Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue | ||
272.7 | Lipidoses (mucolipidoses, Gaucher’s disease) | E75.21 | Fabry disease |
E75.22 | Gaucher disease | ||
E75.240 - E75.242, E75.244 | Niemann-Pick Disease (code range) | ||
E75.3 | Sphingolipidosis, unspecified | ||
E77.0 - E77.9 | Disorders of glycoprotein metabolism | ||
277.5 | Mucopolysaccharidosis | E76.01, E76.02, E76.03, E76.29, E76.3, E76.8, E76.9 | Disorders of glycosaminoglycan metabolism |
279.12 | Wiskott-Aldrich syndrome | D82.0 | Wiskott-Aldrich syndrome |
279.2 | Combined immunity deficiency | D81.0, D81.1, D81.2, D81.6, D81.7, D81.89, D81. | Combined immunodeficiencies |
D81.82 | Activated Phosphoinositide 3-kinase Delta Syndrome [APDS] | ||
282.41, 282.42, 282.49 | Sickle-cell thalassemia code range | D56.0, D56.1, D56.2, D56.3, D56.8, D56.9, D57.40, D57.411, D57.412, D57.419 | Thalassemia |
D57.40, D57.411, D57.412,D57.413,D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.458, D57.459 | Sickle-cell thalassemia | ||
282.60, 282.61, 282.62, 282.63, 282.64, 282.68, 282.69 | Sickle-cell disease code range | D57.00, D57.01, D57.02, D57.03, D57.09,D57.1, D57.20, D57.211, D57.212,D57.213,D57.218, D57.219,D57.80, D57.811, D57.812, D57.813, D57.818, D57.819 | Sickle-cell disease |
284.01 | Constitutional red blood cell aplasia | D61.01 | Constitutional (pure) red blood cell aplasia |
D61.03 | Fanconi anemia (New 10/01/2024) | ||
284.09 | Other constitutional aplastic anemia | D61.09 | Other constitutional aplastic anemia (Fanconi's anemia, congenital pancytopenia) |
284.1 | Pancytopenia | D61.810, D61.811, D61.818 | Pancytopenia |
284.81 | Red cell aplasia (acquired) (adult) (with thymoma) | D60.0, D60.1, D60.8, D60.9 | Acquired pure red cell aplasia |
284.89 | Other specified aplastic anemia | D61.1, D61.2, D61.3, D61.8 | Other aplastic anemias and other bone marrow failure syndromes |
284.9 | Aplastic anemia, unspecified | D61.9 | Aplastic anemia, unspecified |
285.3 | Antineoplastic chemotherapy induced anemia | D64.81 | Anemia due to antineoplastic chemotherapy |
288.00 | Neutropenia, unspecified | D70.9 | Neutropenia, unspecified |
288.01 | Congenital neutropenia | D70.0 | Congenital neutropenia |
288.02 | Cyclic neutropenia | D70.4 | Cyclic neutropenia (Shwachman-Diamond Syndrome) |
288.04 | Neutropenia due to infection | D70.3 | Neutropenia due to infection |
288.09 | Other neutropenia | D70.8 | Other neutropenia |
288.2 | Genetic anomalies of leukocytes (leukocytes adhesion deficiency) | D72.0 | Genetic anomalies of leukocytes |
288.4 | Hemophagocytic syndromes | D76.1, D76.2, D76.3 | Other specified diseases with participation of lymphoreticular and reticulohistiocytic tissue |
288.50 | Leukocytopenia, unspecified | D72.819 | Decreased white blood cell count, unspecified |
288.51 | Lymphocytopenia | D72.810 | Lymphocytopenia |
288.59 | Other decreased white blood cell count | D72.818 | Other decreased white blood cell count |
330.0 | Leukodystrophy (globoid cell, metachromatic, adrrenoleukodystrophy) | E75.23, E75.25, E75.29 | Other sphingolipidosis |
517.3 | Acute chest syndrome (must be recurrent) | D57.01 | Hb-SS disease with acute chest syndrome |
D57.211 | Sickle-cell/Hb-C disease with acute chest syndrome | ||
D57.411 | Sickle-cell thalassemia with acute chest syndrome | ||
D57.811 | Other sickle-cell disorders with acute chest syndrome | ||
593.81 | Vascular disorders of kidney (vaso-occlusive crisis) | N28.0 | Ischemia and infarction of kidney |
756.52 | Osteopetrosis (Albers-Schonberg disease or marble bone disease) | Q78.2 | Osteopetrosis |
V12.59 | Other diseases of circulatory system (stroke) | Z86.79 | Personal history of other diseases of the circulatory system |
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