Covered Conditions

Effective for services performed on or after April 28, 1989: 

For acute leukemia in remission for patients who have a high probability of relapse and who have no human leucocyte antigens (HLA)-matched, the following diagnosis codes are reported:

If ICD-9-CM is applicable, use the following Diagnosis Codes and Descriptions

Diagnosis Code Description 

204.01 Lymphoid leukemia, acute, in remission 

205.01 Myeloid leukemia, acute, in remission 

206.01 Monocytic leukemia, acute, in remission 

207.01 Acute erythremia and erythroleukemia, in remission 

208.01 Leukemia of unspecified cell type, acute, in remission

If ICD-10-CM is applicable, use the following Diagnosis Codes and Descriptions

C91.01 Acute lymphoblastic leukemia, in remission 

C92.01 Acute myeloblastic leukemia, in remission 

C92.41 Acute promyelocytic leukemia, in remission 

C92.51 Acute myelomonocytic leukemia, in remission 

C92.61 Acute myeloid leukemia with 11q23-abnormality in remission

C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission 

C93.01 Acute monoblastic/monocytic leukemia, in remission 

C94.01 Acute erythroid leukemia, in remission 

C94.21 Acute megakaryoblastic leukemia, in remission 

C94.41 Acute parmyelosis with myelofibrosis, in remission

C95.01 Acute leukemia of unspecified cell type, in remission

For resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response the following diagnosis codes are reported:

Autologous Stem Cell Transplantation (AuSCT)

a. General

Autologous stem cell transplantation (ICD-9-CM Procedure Codes 41.01, 41.04, 41.07, and 41.09; ICD-10-PCS codes 30230AZ, 30230G0, 30230Y0, 30233G0, 30233Y0, 30240G0, 30240Y0, 30243G0, 30243Y0, 30250G0, 30250Y0, 30253G0, 30253Y0, 30260G0, 30260Y0, 30263G0, and 30263Y0) is a technique for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (high dose chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies

b. Covered Conditions

1. Effective for services performed on or after April 28, 1989:

Acute leukemia in remission who have a high probability of relapse and who have no human leucocyte antigens (HLA)-matched; 

Resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response;

Recurrent or refractory neuroblastoma; or, 

Advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched donor. 

2. Effective for services performed on or after October 1, 2000:

Single AuSCT is only covered for Durie-Salmon Stage II or III patients that fit the following requirements:

 Newly diagnosed or responsive multiple myeloma. This includes those patients with previously untreated disease, those with at least a partial response to prior chemotherapy (defined as a 50% decrease either in measurable paraprotein [serum and/or urine] or in bone marrow infiltration, sustained for at least 1 month), and those in responsive relapse; and  

 Adequate cardiac, renal, pulmonary, and hepatic function