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:

If ICD-9-CM is applicable, use the following code ranges:

200.00 - 200.08, 

200.10 - 00.18, 

200.20 - 200.28, 

200.80 - 200.88, 

202.00 - 202.08, 

202.80 - 202.88, and 

202.90 - 202.98.

If ICD-10-CM is applicable use the following code ranges:

C82.00 - C85.29, 

C85.80 - C86.6, 

C96.4, and

 C96.Z - C96.9.

For recurrent or refractory neuroblastoma (see ICD-9-CM Neoplasm by site, malignant for the appropriate diagnosis code)