code
stringlengths 4
12
| description
stringlengths 2
264
| codetype
stringclasses 8
values | context
stringlengths 160
15.5k
|
|---|---|---|---|
J9212 | Interferon alfacon-1 inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9001 | DOXORUBICIN PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9370 | VINCRISTINE SULFATE 2MG Injectable Drugs Not on Fee Schedule | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9209 | mesna per 200 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9092 | Cyclophosphamide 2.0 grm inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9017 | Injection, arsenic trioxide, 1 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9090 | Cyclophosphamide 500 MG inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9190 | INJECTION, FLUOROURACIL, 500 MG | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9245 | melphalan HCl 50 mg recon soln 1 each Vial | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
G0267 | Bone marrow or psc harvest | CPT | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9098 | Injection, cytarabine liposome, 10 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9091 | Cyclophosphamide 1.0 grm inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9080 | Cyclophosphamide 200 MG inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9170 | Docetaxel injection | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9270 | Plicamycin (mithramycin) inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9070 | HC Cyclophosphamide Inj Bu100mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9120 | Injection, dactinomycin, 0.5 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9200 | Injection, floxuridine, 500 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9266 | PEGASPARGASE VIAL 3750U 5ML SNIJ | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
30243G0 | Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
38211 | Tumor cell deplete of harvst | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9093 | CYCLOPHOSPHAMIDE LYOPHILIZED 100 MG | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9305 | pemetrexed per 10 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
38232 | PR BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9027 | Injection, clofarabine, 1 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9355 | trastuzumab per 10 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9357 | Valrubicin injection | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9216 | Interferon gamma 1-b inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9260 | METHOTREXATE SODIUM (PF) 50 MG/2ML INJ SOLUTION | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9211 | Injection, idarubicin hydrochloride, 5 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9215 | Interferon alfa-n3 inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9340 | Thiotepa injection | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9290 | Mitomycin 20 MG inj | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9025 | INJECTION, AZACITIDINE, 1 MG | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9300 | QUINACRINE HCL 10 CC/200 MGM | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9219 | Leuprolide acetate implant, 65 mg | HCPCS | Accessed September 10, 2014. |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. |
J9020 | Injection, asparaginase, not otherwise specified, 10,000 units | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9041 | INJECTION, BORTEZOMIB, 0.1 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9055 | INJECTION, CETUXIMAB, 10 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9062 | Cisplatin 50 MG injection | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9045 | INJECTION, CARBOPLATIN, 50 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9263 | oxaliplatin per 0.5 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9060 | INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
G0265 | Cryopresevation Freeze+stora | CPT | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9151 | Injection, daunorubicin citrate, liposomal formulation, 10 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9230 | Mechlorethamine hcl inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38221 | PR DIAGNOSTIC BONE MARROW BIOPSIES | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9140 | Dacarbazine 200 MG inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9100 | INJECTION, CYTARABINE, 100 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9010 | DOXORUBICIN HCL, 50 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38240 | Transplt allo hct/donor | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9015 | Injection, aldesleukin, per single use vial | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38210 | T-cell depletion of harvest | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9303 | panitumumab per 10 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9213 | Interferon alfa-2a inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9380 | TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38212 | Rbc depletion of harvest | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9268 | Pentostatin injection | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38220 | PR DIAGNOSTIC BONE MARROW ASPIRATIONS | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9130 | dacarbazine per 200 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9160 | INJ DENILEUKIN DIFTITOX 300 MCG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9375 | Vincristine sulfate 2 MG inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9291 | Mitomycin 40 MG inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9094 | CYCLOPHOSPHAMIDE LYOPHILIZED 200 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9265 | Paclitaxel injection | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
Q0083 | Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9095 | CYCLOPHOSPHAMIDE LYOPHILIZED 500 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9165 | Injection, diethylstilbestrol diphosphate, 250 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9390 | vinorelbine tartrate per 10 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9250 | METHOTREXATE SODIUM (PF) NON-ONCOLOGY USE 25 MG/ML INJ SOLN | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9218 | LEUPROLIDE ACETATE, PER 1 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9175 | Injection, elliotts'' b solution, 1 ml | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
G0266 | Thawing + expansion froz cel | CPT | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9178 | Inj, epirubicin hcl, 2 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9226 | Supprelin LA implant | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9097 | CYCLOPHOSPHAMIDE LYOPHILIZED 2.0 GM | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
30243Y0 | Transfusion of Autologous Hematopoietic Stem Cells into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU | ICD | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
30243X0 | Transfusion of Autologous Cord Blood Stem Cells into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU | ICD | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9360 | Vinblastine sulfate inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9217 | LUPRON DEPOT IM 1 MONTH PWD FOR SUSP 7.5 | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9065 | Injection, cladribine, per 1 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9600 | Porfimer sodium injection | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9035 | INJECTION, BEVACIZUMAB, 10 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9181 | INJECTION, ETOPOSIDE, 10 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9031 | Bcg live intravesical vac | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9293 | mitoxantrone per 5 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9320 | Streptozocin injection | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9096 | CYCLOPHOSPHAMIDE LYOPHILIZED 1.0 GM | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9182 | Etoposide 100 MG inj | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9280 | mitomycin per 5 mg | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9395 | INJECTION, FULVESTRANT, 25 MG | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
J9206 | IRINOTECN 20MG 500MG 25ML SNIV | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
Q0084 | HC CHEMOTHERAPY - IM PHYS | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
38214 | Volume deplete of harvest | HCPCS | |CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.