I. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)
a. General
Allogeneic stem cell transplantation (ICD-9-CM Procedure Codes 41.02,
41.03, 41.05, and 41.08,; ICD-10-PCS codes 30230G1, 30230Y1, 30233G1,
30233Y1, 30240G1, 30240Y1, 30243G1, 30243Y1, 30250G1, 30250Y1,
30253G1, 30253Y1, 30260G1, 30260Y1, 30263G1, and 30263Y1) is a
procedure in which a portion of a healthy donor's stem cells are obtained and
prepared for intravenous infusion to restore normal hematopoietic function in
recipients having an inherited or acquired hematopoietic deficiency or defect.
Expenses incurred by a donor are a covered benefit to the recipient/beneficiary
but, except for physician services, are not paid separately. Services to the
donor include physician services, hospital care in connection with screening
the stem cell, and ordinary follow-up care.
b. Covered Conditions
i. Effective for services performed on or after August 1, 1978:
For the treatment of leukemia, leukemia in remission, or aplastic anemia
when it is reasonable and necessary;
ii. Effective for services performed on or after June 3, 1985:
For the treatment of severe combined immunodeficiency disease (SCID),
and for the treatment of Wiskott-Aldrich syndrome;
iii. Effective for services performed on or after August 4, 2010:
For the treatment of Myelodysplastic Syndromes (MDS) pursuant to
Coverage with Evidence Development (CED) in the context of a Medicareapproved,
prospective clinical study.
