![]() ![]() Specific cell depletion within harvest, T-cell depletion Thawing of previously frozen harvest, with washing Thawing of previously frozen harvest, without washing Transplant preparation of hematopoietic progenitor cells cryopreservation and storage Management of recipient hematopoietic progenitor cell donor search and cell acquisitionīlood-derived hematopoietic progenitor cell harvesting for transplantation, per collection allogenic Codes requiring a 7th character are represented by "+":ĬPT codes covered if selection criteria are met: Information in the below has been added for clarification purposes. Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code CPB 0871 - Hematopoietic Cell Transplantation for Inherited Metabolic Disorders and Genetic Diseases.CPB 0838 - Hematopoietic Cell Transplantation for Myelofibrosis.CPB 0836 - Hematopoietic Cell Transplantation for Myelodysplastic Syndrome. ![]() CPB 0833 - Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia.CPB 0830 - Hematopoietic Cell Transplantation for Primary Immunodeficiency Disorders.CPB 0811 - Hematopoietic Cell Transplantation for Solid Tumors in Adults.CPB 0674 - Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia.CPB 0640 - Hematopoietic Cell Transplantation for Selected Leukemias.CPB 0635 - Hematopoietic Cell Transplantation for Ovarian Cancer.CPB 0634 - Non-myeloablative Hematopoietic Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant).CPB 0627 - Hematopietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes.CPB 0626 - Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia.CPB 0617 - Hematopoietic Cell Transplantation for Testicular Cancer.CPB 0606 - Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications.CPB 0507 - Hematopoietic Cell Transplantation for Breast Cancer.CPB 0497 - Hematopoietic Cell Transplantation for Multiple Myeloma.CPB 0496 - Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors.CPB 0495 - Hematopoietic Cell Transplantation for Hodgkin's Disease.CPB 0494 - Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma.Medical necessity criteria and plan limitations and exclusions may apply. Performance of HLA typing and identification of a suitable donor does not, in and of itself, guarantee coverage of allogeneic bone marrow or peripheral stem cell transplantation. When a covered family member of a newborn infant has a medically necessary indication for an allogeneic bone marrow transplant and wishes to use umbilical cord blood stem cells as an alternative, Aetna covers the testing of umbilical cord blood for compatibility for transplant under the potential recipient’s plan. Note: For medical necessity related to Omisirge - see CPB 1032 - Omidubicel-onlv (Omisirge). Umbilical cord blood transplantation using ex-vivo expansion.Use of mesenchymal stromal cells-derived extracellular vesicles for the prevention or treatment of graft-versus-host disease.Use of enzyme-linked immunospot (ELISPOT) interferon-gamma release assay for prediction of the risk of cytomegalovirus infection in hematopoietic cell transplant recipients.Co-transplantation of multipotent mesenchymal stromal cells in allogeneic hematopoietic stem cell transplantation.The following procedures are considered experimental and investigational because the effectiveness of these approaches has not been established: Stem cell boosting in the setting of graft failure following an approved allogeneic hematopoietic stem cell transplant.Such use is not related to the person’s current medical care Note: The harvesting, freezing and/or storing umbilical cord blood of non-diseased persons for possible future use is not considered treatment of disease or injury. The short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment when there is a match.Umbilical cord blood stem cells is considered an acceptable alternative to conventional bone marrow or peripheral stem cells for allogeneic transplant.Compatibility testing of prospective donors who are close family members (first-degree relatives (i.e., parents, siblings and children) or second degree relatives (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling)) and harvesting and short-term storage of peripheral stem cells or bone marrow from the identified donor when an allogeneic bone marrow or peripheral stem cell transplant is authorized by Aetna.This Clinical Policy Bulletin addresses stem cells for hematopoietic cell transplant.Īetna considers the following indications as medically necessary (unless otherwise stated): Number: 0190 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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