![]() ![]() Codes requiring a 7th character are represented by "+":ĬPT codes covered if selection criteria are met:ģ8204 - 38205, 38207 - 38215, 38230 - 38240īone marrow or stem cell services/procedures-allogenic and transplantation and post-transplantation cellular infusions Information in the below has been added for clarification purposes. Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code Testicular cancer (see CPB 0617 - Hematopoietic Cell Transplantation for Testicular Cancer).Renal cancer (see CPB 0811 - Hematopoietic Cell Transplantation for Solid Tumors in Adults).Ovarian cancer (see CPB 0635 - Hematopoietic Cell Transplantation for Ovarian Cancer).Melanoma (see CPB 0811 - Hematopoietic Cell Transplantation for Solid Tumors in Adults).Inherited hemophagocytic lymphohistiocytosis.Essential thrombocythemia and polycythemia vera (see CPB 0606 - Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications).Breast cancer (see CPB 0507 - Hematopoietic Cell Transplantation for Breast Cancer).Autoimmune diseases (see CPB 0606 - Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications).Thalassemia major (see CPB 0626 - Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia).Īetna considers non-myeloablative hematopoietic cell transplantation (mini-allograft) experimental and investigational for any of the following diseases because it has not been established that a conventional allogeneic hematopoietic cell transplant is effective in treating these conditions (not an all-inclusive list):.Sickle cell anemia (see CPB 0626 - Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia).Non-Hodgkin's lymphoma (NHL, see CPB 0494 - Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma).Neuroblastoma (see CPB 0496 - Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors).Myelodysplasia/myelodysplastic syndrome (see CPB 0836 - Hematopoietic Cell Transplantation for Myelodysplastic Syndrome).Myelofibrosis (see CPB 0838 - Hematopoietic Cell Transplantation for Myelofibrosis).Multiple myeloma (MM, see CPB 0497 - Hematopoietic Cell Transplantation for Multiple Myeloma).Hodgkin's disease (HD, see CPB 0495 - Hematopoietic Cell Transplantation for Hodgkin's Disease).Chronic myelogenous leukemia (CML) (see CPB 0674 - Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia).Chronic lymphocytic leukemia (CLL) (see CPB 0494 - Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma).Aplastic anemia (AA) (including paroxysmal nocturnal hemoglobinuria (PNH), see CPB 0627 - Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes).Acute myelogenous leukemia (AML, see CPB 0640 - Hematopoietic Cell Transplantation for Selected Leukemias).Acute lymphoblastic leukemia (ALL, see CPB 0640 - Hematopoietic Cell Transplantation for Selected Leukemias).In these cases, mini-allografting represents a technical modification of an established procedure. Persons who are unable to tolerate a conventional allogeneic hematopoietic cell transplant may be able to tolerate a milder, non-myeloablative conditioning regimen. Aetna considers non-myeloablative hematopoietic cell transplantation (mini-allograft) medically necessary for members with any of the following diseases for which conventional allogeneic hematopoietic cell transplantation is considered an established alternative.Number: 0634 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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