Noncovered Conditions

Insufficient data exist to establish definite conclusions regarding the efficacy of autologous stem cell transplantation for the following conditions:

• Acute leukemia not in remission: 

o If ICD-9-CM is applicable, diagnosis codes 204.00, 205.00, 206.00, 207.00 and 208.00 are noncovered; 

o If ICD-10-CM is applicable, diagnosis codes C91.00, C92.00, C92.40, C92.50, C92.60, C92.A0, C93.00, C94.00, and C95.00 are noncovered. 

• Chronic granulocytic leukemia: 

o If ICD-9-CM is applicable, diagnosis codes 205.10 and 205.11;

o If ICD-10-CM is applicable, diagnosis codes C92.10 and C92.11. 

• Solid tumors (other than neuroblastoma):

o If ICD-9-CM is applicable, diagnosis codes 140.0-199.1; 

o If ICD-10-CM is applicable, diagnosis codes C00.0 - C80.2 and D00.0 - D09.9. 

• Multiple myeloma (ICD-9-CM codes 203.00 and 238.6), through September 30, 2000. 

• Tandem transplantation (multiple rounds of autologous stem cell transplantation) for patients with multiple myeloma 

o If ICD-9-CM is applicable, diagnosis codes 203.00 and 238.6 and,

o If ICD-10-CM is applicable, diagnosis codes C90.00 and D47.Z9) 

• Non-primary (AL) amyloidosis, 

o If ICD-9-CM is applicable, diagnosis code 277.3. Effective October 1, 2000; ICD-9-CM code 277.3 was expanded to codes 277.30, 277.31, and 277.39 effective October 1, 2006. 

o If ICD-10-CM is applicable, diagnosis codes are E85.0 - E85.9. or 

• Primary (AL) amyloidosis 

o If ICD-9-CM is applicable, diagnosis codes 277.30, 277.31, and 277.39 and for Medicare beneficiaries age 64 or older, effective October 1, 2000, through March 14, 2005.

o If ICD-10-CM is applicable, diagnosis codes are E85.0 - E85.9. 

NOTE: Coverage for conditions other than these specifically designated as covered or non-covered is left to the discretion of the A/B MAC (A).

Billing for Stem Cell Transplantation

 Billing for Allogeneic Stem Cell Transplants

1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the costs of the following services: 

• National Marrow Donor Program fees, if applicable, for stem cells from an unrelated donor; 

• Tissue typing of donor and recipient;

 • Donor evaluation; 

• Physician pre-admission/pre-procedure donor evaluation services; 

• Costs associated with harvesting procedure (e.g., general routine and special care services, procedure/operating room and other ancillary services, apheresis services, etc.);

• Post-operative/post-procedure evaluation of donor; and 

• Preparation and processing of stem cells. 

Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting, and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment. 

Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are obtained from a donor (other than the recipient himself or herself). Acquisition charges do not apply to autologous transplants (transplanted stem cells are obtained from the recipient himself or herself), because autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the hospital may bill and receive payment (see Pub. 100-04, chapter 4, §231.10 and paragraph B of this section for information regarding billing for autologous stem cell transplants).