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A.8.01.20
Hematopoietic cell transplantation (HCT) refers to a procedure by which hematopoietic stem cells are infused to restore bone marrow 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 (allogeneic HCT [allo-HCT]). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates. Although umbilical cord blood is an allogeneic source, the stem cells in it are antigenically “naïve” and thus are associated with a lower incidence of rejection or graft-versus-host disease. Umbilical cord blood is discussed in greater detail in the Placental and Umbilical Cord Blood as a Source of Stem Cells policy.
Treatment for Non-Hodgkin Lymphoma
Hematopoietic Cell TransplantationImmunologic 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 for achieving a successful outcome. Compatibility is established by typing of human leukocyte antigens (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 ConditioningThe 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 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 the 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 graft-versus-host disease.
Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation
Reduced-intensity conditioning (RIC) 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 RIC 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 RIC 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. RIC regimens range from nearly total myeloablative to minimally myeloablative with lymphoablation, with intensity tailored to specific diseases and patient condition. Patients who undergo RIC with allogeneic HCT initially demonstrate donor cell engraftment and bone marrow mixed chimerism. Most will subsequently convert to full-donor chimerism. For the purposes of this policy, reduced-intensity conditioning refers to all conditioning regimens intended to be nonmyeloablative.
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 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 unless the Member receives prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi.
For individuals with non-Hodgkin lymphoma (NHL) B-cell subtypes considered aggressive (except mantle cell lymphoma), either allogeneic hematopoietic cell transplantation (HCT) using a myeloablative conditioning regimen or autologous HCT may be considered medically necessary:
as salvage therapy for individuals who do not achieve a complete remission (CR) after first-line treatment (induction) with a full course of standard-dose chemotherapy;
to achieve or consolidate CR for those in a chemosensitive first or subsequent relapse; or
to consolidate a first CR in individuals with diffuse large B-cell lymphoma, with an age-adjusted International Prognostic Index score that predicts a high- or high-intermediate risk of relapse.
For individuals with mantle cell lymphoma:
Autologous HCT may be considered medically necessary to consolidate a first remission.
Allogeneic HCT, with myeloablative or reduced-intensity conditioning, may be considered medically necessary as salvage therapy.
Autologous HCT is considered investigational as salvage therapy.
Allogeneic HCT is considered investigational to consolidate a first remission.
For individuals with NHL B-cell subtypes considered indolent, either allogeneic HCT using a myeloablative conditioning regimen or autologous HCT may be considered medically necessary:
as salvage therapy for individuals who do not achieve CR after first-line treatment (induction) with a full course of standard-dose chemotherapy; or
to achieve or consolidate CR for those in a first or subsequent chemosensitive relapse, whether or not their lymphoma has transformed to a higher grade.
Either autologous HCT or allogeneic HCT is considered investigational:
as initial therapy (i.e., without a full course of standard-dose induction chemotherapy) for any NHL;
to consolidate a first CR for individuals with diffuse large B-cell lymphoma and an International Prognostic Index score that predicts a low- or low-intermediate risk of relapse;
to consolidate a first CR for those with indolent NHL B-cell subtypes.
For individuals with mature T-cell or natural killer cell (peripheral T-cell) neoplasms:
Autologous HCT may be considered medically necessary to consolidate a first CR in high-risk subtypes. (see Policy Guidelines).
Autologous or allogeneic HCT (myeloablative or reduced-intensity conditioning) may be considered medically necessary as salvage therapy.
Allogeneic HCT is considered investigational to consolidate a first remission.
For individuals with hepatosplenic T-cell lymphoma:
Allogenic HCT may be considered medically necessary to consolidate a first CR or partial response.
Autologous HCT may be considered medically necessary to consolidate a first response if a suitable donor is not available or for individuals who are ineligible for allogeneic HCT.
Autologous or allogeneic HCT as initial therapy (i.e., without a full course of standard-dose induction chemotherapy) is considered investigational.
Reduced-intensity conditioning allogeneic HCT may be considered medically necessary as a treatment of NHL in individuals who meet criteria for an allogeneic HCT but who do not qualify for a myeloablative allogeneic HCT (see Policy Guidelines).
Tandem transplants are considered investigational to treat patients with any stage, grade, or subtype of NHL.
Note: Small lymphocytic lymphoma may be considered a node-based variant of chronic lymphocytic leukemia. Therefore, small lymphocytic lymphoma is considered along with chronic lymphocytic leukemia in the Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma policy. Lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia is considered in the Hematopoietic Cell Transplantation for Primary Amyloidosis or Waldenstrom's Macroglobulinemia policy.
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.
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
Reduced-intensity conditioning (RIC) would be considered an option in patients who meet criteria for allogeneic hematopoietic cell transplantation (HCT), but whose age (typically older than 55 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy) preclude the use of a standard conditioning regimen.
In patients who qualify for a myeloablative allogeneic HCT on the basis of overall health and disease status, allogeneic HCT using either myeloablative or RIC may be considered. However, a myeloablative conditioning regimen with allogeneic HCT may benefit younger patients with good performance status and minimal comorbidities more than allogeneic HCT with RIC.
A chemosensitive relapse is defined as relapsed non-Hodgkin lymphoma that does not progress during or immediately after standard-dose induction chemotherapy (i.e., achieves stable disease or a partial response).
Transformation describes a lymphoma whose histologic pattern has evolved to a higher-grade lymphoma. Transformed lymphomas typically evolve from a nodular pattern to a diffuse pattern.
Tandem transplants usually are defined as the planned administration of two (2) successive cycles of high-dose myeloablative chemotherapy, each followed by infusion of autologous hematopoietic stem cells, whether or not there is evidence of persistent disease following the first treatment cycle. Sometimes, the second cycle may use non-myeloablative immunosuppressive conditioning followed by infusion of allogeneic stem cells.
The term salvage therapy describes therapy given to patientswith refractory or relapsed disease. For patients with peripheral T-cell lymphoma, salvage therapy includes patients who do not achieve a complete response (eg, achieve only a partial response, have no response, or have progressive disease) with first-line induction chemotherapy (refractory disease) or who relapse after achieving a complete response with first-line induction chemotherapy. For mantle cell lymphoma, salvage therapy includes patients with progressive disease with first-line induction chemotherapy (refractory disease) or in patients who relapse after a complete or partial response after initial induction chemotherapy, or patients who fail a previous autologous HCT.
High-risk (aggressive) T-cell and natural killer cell neoplasms are a clinically heterogeneous group of rare disorders, most of which have an aggressive clinical course and poor prognosis. The exception includes the following subtypes, which typically have a relatively indolent and protracted course: T-cell large granulocyte leukemia, chronic lymphoproliferative disorder of natural killer cells, early-stage mycosis fungoides, primary cutaneous anaplastic large-cell lymphoma, and anaplastic lymphoma kinase-anaplastic large-cell lymphomas.
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.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of 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. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. Allogeneic stem-cell support to treat NHL that progresses or relapses soon after a course of HDC with autologous stem-cell support changed to investigational. Title changed to "Stem-Cell Transplantation" and the terminology "High Dose Chemotherapy" removed
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
6/04/2010: Policy description updated to include risk groups and adverse risk factors. Policy statement updated to include medically necessary indications for allogeneic SCT and/or autologous SCT and medically necessary indications for reduced intensity conditioning allogeneic SCT. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007.
04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. Also revised the policy statement to break out peripheral T-cell lymphoma; added statements as medically necessary for autologous to consolidate first remission in specific situations and autologous and allogeneic as salvage therapy, and as investigational regarding allogeneic HSCT to consolidate a first complete remission. Policy guidelines updated regarding high-risk peripheral T-cell lymphoma.
05/08/2012: Policy statement regarding peripheral T-cell lymphomas revised to clarify that this includes mature T-cell and NK-cell neoplasms.
04/16/2013: Policy reviewed; no changes.
04/01/2014: Policy reviewed; description updated regarding Mature T-cell and NK-cell neoplasms and Mantle Cell Lymphoma.
03/13/2015: Policy reviewed; description updated. "Stem-cell transplantation" changed to "hematopoietic stem-cell transplantation" throughout policy. Investigational statement criteria for autologous and allogeneic HSCT updated to change "NHL subtypes" to "NHL B-cell subtypes." In first medically necessary statement for patients with mature T-cell or NK-cell (peripheral T-cell) neoplasms, "high-risk peripheral T-cell lymphoma" changed to "high-risk subtypes." Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms.
08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446.
05/25/2016: Policy number A.8.01.20 added. Policy Guidelines updated to add medically necessary and investigative definitions.
09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4.
12/22/2017: Policy updated to change "hematopoietic stem-cell transplantation" to "hematopoietic cell transplantation" throughout the policy. Policy description updated regarding the 2016 WHO classification and FDA regulation. Policy statements unchanged. Code Reference section updated to remove deleted procedure codes 30230G1, 30233G1, 30240G1, 30243G1, 30230Y1, 30233Y1, 30240Y1, and 30243Y1. Added new 2018 CPT code 38222. Revised descriptions for CPT codes 38220 and 38221 effective 01/01/2018.
02/09/2018: Policy description updated regarding mature t-cell and NK-cell neoplasms. Policy statements unchanged.
03/08/2019: Policy description updated regarding mature B-cell neoplasms. 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 30230U2, 30233U2, 30240U2, 30243U2, 30230U3, 30233U3, 30240U3, 30243U3, 30230U4, 30233U4, 30240U4, and 30243U4, effective 10/01/2019.
02/19/2020: Policy description extensively revised. Policy statements unchanged.
03/04/2021: Policy description updated. Minor edit made to policy statement regarding patients with mantle cell lymphoma. Intent 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 C84.7A effective 10/01/2021.
12/22/2021: Code Reference section updated to make note of deleted ICD-10 procedure codes.
02/16/2022: Policy reviewed; no changes.
03/29/2023: Policy reviewed. Policy statements updated to change "patients" to "individuals." Added policy statement for individuals with hepatosplenic T-cell lymphoma. Code Reference section updated to remove deleted ICD-10 procedure codes 30230G0, 30240G0, 30230G2, 30240G2, 30230G3, 30240G3, 30230G4, 30240G4, 30230U2, 30240U2, 30230U3, 30240U3, 30230U4, 30240U4, 30230Y2, 30240Y2, 30230Y3, 30240Y3, 30230Y4, 30240Y4, 30230Y0, and 30240Y0.
12/21/2023: Code Reference section updated to revise the code description for CPT code 96446, effective 01/01/2024.
02/23/2024: Policy reviewed; no changes.
10/01/2024: Code Reference section updated to add new ICD-10 diagnosis codes C86.00, C86.10, C86.20, C86.30, C86.40, C86.50, C86.60, and C88.40.
04/02/2025: Policy description updated with minor changes. Policy statements unchanged. Policy Guidelines updated.
Blue Cross Blue Shield Association Policy # 8.01.20
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 | ||
38206 | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous | ||
38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215 | Transplant preparation of hematopoietic progenitor cells code range | ||
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 | ||
38241 | Hematopoietic progenitor cell (HPC); autologous transplantation | ||
38242 | Allogeneic lymphocyte infusions | ||
86812,86813, 86816, 86817, 86821,86825, 86826 | HLA typing code range | ||
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 infusion technique; up to 1 hour, single or initial substance/drug | ||
96413 | Chemotherapy administration, intravenous infusion technique; each additional hour, 1 to 8 hours, (List separately in addition to code for primary procedure) | ||
96515 | Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump | ||
96517 | 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 | |||
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 or pre-and post-transplant care in the global definition | ||
ICD-9 Procedure | ICD-10 Procedure | ||
41.01, 41.02, 41.03 | Bone marrow code range | 30233G0, 30243G0 | Transfusion of autologous bone marrow into vein (peripheral or central, percutaneous approach |
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 | ||
41.04, 41.05, 41.07, 41.08 | Hematopoietic stem cell transplant code range | 30233Y0, 30243Y0 | Transfusion of hematopoietic stem cells (autologous or nonautologous ) into vein (peripheral or central), percutaneous approach |
41.09 | Autologous bone marrow transplant with purging | 30233Y0, 30243Y0 | (See description above) |
41.91 | Aspiration of bone marrow from donor for transplant | 079T30Z, 079T3ZZ | Drainage of bone marrow, with or without draining device, percutaneous approach |
07DQ3ZZ, 07DR3ZZ, 07DS3ZZ | Extraction of sternum, iliac, or vertebral bone marrow, percutaneous approach | ||
99.25 | Injection or infusion of cancer chemotherapeutic substance | 3E03305 | Introduction of other antineoplastic into peripheral vein, percutaneous approach |
99.79 | Other therapeutic apheresis (includes harvest of stem cells) | 6A550ZT, 6A550ZV, 6A551ZT, 6A551ZV | Pheresis of cord blood or hematopoietic stem cells, single or multiple |
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
200.00, 200.01, 200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08 | Reticulosarcoma | C83.30 - C83.39 | Diffuse large B-cell lymphoma |
200.10, 200.11, 200.12, 200.13, 200.14, 200.15, 200.16, 200.17, 200.18 | Lymphosarcoma | C83.50 - C83.59 | Lymphoblastic (diffuse) lymphoma |
200.20, 200.21, 200.22, 200.23, 200.24, 200.25, 200.26, 200.27, 200.28 | Burkitt's tumor or lymphoma | C83.70 - C83.79 | Burkitt lymphoma |
200.30, 200.31, 200.32, 200.33, 200.34, 200.35, 200.36, 200.37, 200.38 | Marginal zone lymphoma | C83.80 - C83.89, C88.4 | Other non-follicular lymphoma |
200.40, 200.41, 200.42, 200.43, 200.44, 200.45, 200.46, 200.47, 200.48 | Mantel cell lymphoma | C83.10 - C83.19 | Mantle cell lymphoma |
200.50, 200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 200.57, 200.58 | Primary central nervous system lymphoma | C83.31 - C83.39 | Mantle cell lymphoma |
C83.80 - C83.89 | Other non-follicular lymphoma | ||
200.60, 200.61, 200.62, 200.63, 200.64, 200.65, 200.66, 200.67, 200.68 | Anaplastic large cell lymphoma | C84.60 - C84.69 | Anaplastic large cell lymphoma, ALK-positive |
C84.70 - C84.7A | Anaplastic large cell lymphoma, ALK-negative | ||
200.70, 200.71, 200.72, 200.73, 200.74, 200.75, 200.76, 200.77, 200.78 | Large cell lymphoma | C83.31 - C83.39 | Diffuse large B-cell lymphoma |
C85.20 - C85.29 | Mediastinal (thymic) large B-cell lymphoma | ||
200.80, 200.81, 200.82, 200.83, 200.84, 200.85, 200.86, 200.87, 200.88 | Other named variants of lymphosarcoma and reticulosarcoma | C83.00 - C83.09 | Small cell B-cell lymphoma |
C83.80 - C83.89 | Other non-follicular lymphoma | ||
C83.90 - C83.99 | Non-follicular (diffuse) lymphoma, unspecified | ||
C86.5 | Angioimmunoblastic T-cell lymphoma | ||
C86.6 | Primary cutaneous CD30-positive T-cell proliferations | ||
202.80, 202.81, 202.82, 202.83, 202.84, 202.85, 202.86, 202.87, 202.88 | Other malignant lymphomas (Non-Hodgkin's lymphomas) code range | C82.50 - C82.59 | Diffuse follicle center lymphoma |
C84.90 - C84.99 | Mature T/NK lymphomas, unspecified | ||
C84.A0 - C84.A9 | Cutaneous T-cell lymphoma, unspecified | ||
C84.Z0 - C84.Z9 | Other mature T/NK-cell lymphoma | ||
C85.10 - C85.19 | Other specified and unspecified types of non-Hodgkin lymphoma | ||
C85.80 - C85.89 | Other specified types of non-Hodgkin lymphoma | ||
C85.90 - C85.99 | Non-Hodgkin lymphoma, unspecified | ||
C86.00, C86.10, C86.20, C86.30, C86.40, C86.50, C86.60 | Other specified types T/NK-cell lymphoma (C86.00, C86.10, C86.20, C86.30, C86.40, C86.50, C86.60 New 10/01/2024) | ||
C88.40 | Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission (New 10/01/2024) |
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