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24.4.3.2 Bone Marrow/Stem Cell Transplants
The following procedure codes should be used to submit claims for reimbursement of bone marrow/stem cell transplantation procedures:
Bone marrow/stem cell transplants must be prior authorized. Prior authorization must be obtained by both the facility and the physician. Services must be provided in a CSHCN Services Program-enrolled stem cell transplant center. The TMHP-CSHCN Services Program reviews applications from facilities that attest they meet the guidelines set forth by ASBMT and coordinates the enrollment process. TMHP maintains a current listing of enrolled centers.
Refer to: Section 3.1.8, "Specialty Team/Center Enrollment," on page 3-4 for more detailed information about requirements and approval.
Providers may fax prior authorization requests to 1-512-514-4222. Refer to the CSHCN Services Program Prior Authorization Request for Bone Marrow/Stem Cell or Renal Transplant form on page B-4.
The following additional information must be submitted with the prior authorization request:
• Indicate whether the client is diagnosed with chronic myelogenous leukemia (CML) in blast crisis.
•Specify the type of transplant to be performed:
•Allogenic.
•Matched related.
•Matched nonrelated.
•Autologous.
•Other (specify).
•Indicate status of client:
•1st remission.
•2nd remission.
•Relapse.
•Other (specify).
The CSHCN Services Program does not authorize the following:
•Stem cell transplants for clients beyond second remission (e.g., in relapse after 2nd remission or in 3rd remission).
•Stem cell transplants for patients in relapse with acute lymphoblastic leukemia, acute nonlymphoblastic leukemia, neuroblastoma, Hodgkin's, or nonHodgkin's lymphoma.
•Human leukocyte antigen (HLA)-typing of possible donors.
The CSHCN Services Program may cover only autologous and matched related and matched nonrelated allogenic transplants (e.g., HLA genotypically identical or HLA phenotypically identical, related and nonrelated), for the following diagnosis codes:
Autologous Transplants
|
Diagnosis Code
|
Description
|
|
1860
|
Malignant neoplasm of testes
|
|
1869
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Malignant neoplasm of other and unspecified testis
|
|
20030
|
Marginal zone lymphoma, unspecified site, extranodal and solid organ sites
|
|
20031
|
Marginal zone lymphoma, lymph nodes of head, face, and neck
|
|
20032
|
Marginal zone lymphoma, intrathoracic lymph nodes
|
|
20033
|
Marginal zone lymphoma, intra-abdominal lymph nodes
|
|
20034
|
Marginal zone lymphoma, lymph nodes of axilla and upper limb
|
|
20035
|
Marginal zone lymphoma, lymph nodes of inguinal region and lower limb
|
|
20036
|
Marginal zone lymphoma, intrapelvic lymph nodes
|
|
20037
|
Marginal zone lymphoma, spleen
|
|
20038
|
Marginal zone lymphoma, lymph nodes of multiple sites
|
|
20040
|
Mantle cell lymphoma, unspecified site, extranodal and solid organ sites
|
|
20041
|
Mantle cell lymphoma, lymph nodes of head, face, and neck
|
|
20042
|
Mantle cell lymphoma, intrathoracic lymph nodes
|
|
20043
|
Mantle cell lymphoma, intra-abdominal lymph nodes
|
|
20044
|
Mantle cell lymphoma, lymph nodes of axilla and upper limb
|
|
20045
|
Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
|
|
20046
|
Mantle cell lymphoma, intrapelvic lymph nodes
|
|
20047
|
Mantle cell lymphoma, spleen
|
|
20048
|
Mantle cell lymphoma, lymph nodes of multiple sites
|
|
20050
|
Primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
|
|
20051
|
Primary central nervous system lymphoma, lymph nodes of head, face, and neck
|
|
20052
|
Primary central nervous system lymphoma, intrathoracic lymph nodes
|
|
20053
|
Primary central nervous system lymphoma, intra-abdominal lymph nodes
|
|
20054
|
Primary central nervous system lymphoma, lymph nodes of axilla and upper limb
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|
20055
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Primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
|
|
20056
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Primary central nervous system lymphoma, intrapelvic lymph nodes
|
|
20057
|
Primary central nervous system lymphoma, spleen
|
|
20058
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Primary central nervous system lymphoma, lymph nodes of multiple sites
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|
20060
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Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
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|
20061
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Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
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20062
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Anaplastic large cell lymphoma, intrathoracic lymph nodes
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|
20063
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Anaplastic large cell lymphoma, intra-abdominal lymph nodes
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|
20064
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Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
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|
20065
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Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
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|
20066
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Anaplastic large cell lymphoma
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|
20067
|
Anaplastic large cell lymphoma, spleen
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|
20068
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Anaplastic large cell lymphoma, lymph nodes of multiple sites
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|
20070
|
Large cell lymphoma, unspecified site, extranodal and solid organ sites
|
|
20071
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Large cell lymphoma, lymph nodes of head, face, and neck
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|
20072
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Large cell lymphoma, intrathoracic lymph nodes
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|
20073
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Large cell lymphoma, intra-abdominal lymph nodes
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|
20074
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Large cell lymphoma, lymph nodes of axilla and upper limb
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|
20075
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Large cell lymphoma, lymph nodes of inguinal region and lower limb
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|
20076
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Large cell lymphoma, intrapelvic lymph nodes
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|
20077
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Large cell lymphoma, spleen
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|
20078
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Large cell lymphoma, lymph nodes of multiple sites
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|
20270
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Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites
|
|
20271
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Peripheral T cell lymphoma, lymph nodes of head, face, and neck
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|
20272
|
Peripheral T cell lymphoma, intrathoracic lymph nodes
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|
20273
|
Peripheral T cell lymphoma, intra-abdominal lymph nodes
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|
20274
|
Peripheral T cell lymphoma, lymph nodes of axilla and upper limb
|
|
20275
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Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb
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|
20276
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Peripheral T cell lymphoma, intrapelvic lymph nodes
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20277
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Peripheral T cell lymphoma, spleen
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20278
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Peripheral T cell lymphoma, lymph nodes of multiple sites
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20300
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Multiple myeloma without mention of remission
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20301
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Multiple myeloma in remission
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20310
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Plasma cell leukemia, without mention of remission
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20311
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Plasma cell leukemia, in remission
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20380
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Other immunoproliferative neoplasms, without mention of remission
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20381
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Other immunoproliferative neoplasms, in remission
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20400
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Lymphoid leukemia, acute, without mention of remission
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|
20401
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Lymphoid leukemia, acute, in remission
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20410
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Lymphoid leukemia, chronic, without mention of remission
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20411
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Lymphoid leukemia, chronic, in remission
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20420
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Lymphoid leukemia, subacute, without mention of remission
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|
20421
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Lymphoid leukemia, subacute, in remission
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20480
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Other lymphoid leukemia, without mention of remission
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|
20481
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Other lymphoid leukemia, in remission
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20490
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Unspecified lymphoid leukemia, without mention of remission
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|
20491
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Unspecified lymphoid leukemia, in remission
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20510
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Myeloid leukemia, chronic, without mention of remission
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28481
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Red cell aplasia (acquired) (adult) (with thymoma)
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|
28489
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Other specified aplastic anemias
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V1562
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Family history of malignant neoplasm, bladder
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Stem transplants may be reimbursed for clients with diagnosis codes 1860, Malignant neoplasm of undescended testis, and 1869, Malignant neoplasm of other and unspecified testis, who have only a partial response to their second line standard dose platinum therapy or clients who have minimal to moderate disease and a less than complete response to third-line standard-dose platinum therapy.
Allogenic Transplants
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Diagnosis Code
|
Description
|
|
20030
|
Marginal zone lymphoma, unspecified site, extranodal and solid organ sites
|
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20031
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Marginal zone lymphoma, lymph nodes of head, face, and neck
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|
20032
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Marginal zone lymphoma, intrathoracic lymph nodes
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|
20033
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Marginal zone lymphoma, intra-abdominal lymph nodes
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|
20034
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Marginal zone lymphoma, lymph nodes of axilla and upper limb
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|
20035
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Marginal zone lymphoma, lymph nodes of inguinal region and lower limb
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|
20036
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Marginal zone lymphoma, intrapelvic lymph nodes
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20037
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Marginal zone lymphoma, spleen
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20038
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Marginal zone lymphoma, lymph nodes of multiple sites
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20040
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Mantle cell lymphoma, unspecified site, extranodal and solid organ sites
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20041
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Mantle cell lymphoma, lymph nodes of head, face, and neck
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|
20042
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Mantle cell lymphoma, intrathoracic lymph nodes
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|
20043
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Mantle cell lymphoma, intra-abdominal lymph nodes
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|
20044
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Mantle cell lymphoma, lymph nodes of axilla and upper limb
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|
20045
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Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
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|
20046
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Mantle cell lymphoma, intrapelvic lymph nodes
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|
20047
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Mantle cell lymphoma, spleen
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|
20048
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Mantle cell lymphoma, lymph nodes of multiple sites
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|
20050
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Primary central nervous system lymphoma, unspecified site, extranodal and solid organ sites
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|
20051
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Primary central nervous system lymphoma, lymph nodes of head, face, and neck
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|
20052
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Primary central nervous system lymphoma, intrathoracic lymph nodes
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|
20053
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Primary central nervous system lymphoma, intra-abdominal lymph nodes
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|
20054
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Primary central nervous system lymphoma, lymph nodes of axilla and upper limb
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|
20055
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Primary central nervous system lymphoma, lymph nodes of inguinal region and lower limb
|
|
20056
|
Primary central nervous system lymphoma, intrapelvic lymph nodes
|
|
20057
|
Primary central nervous system lymphoma, spleen
|
|
20058
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Primary central nervous system lymphoma, lymph nodes of multiple sites
|
|
20060
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Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ sites
|
|
20061
|
Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
|
|
20062
|
Anaplastic large cell lymphoma, intrathoracic lymph nodes
|
|
20063
|
Anaplastic large cell lymphoma, intra-abdominal lymph nodes
|
|
20064
|
Anaplastic large cell lymphoma, lymph nodes of axilla and upper limb
|
|
20065
|
Anaplastic large cell lymphoma, lymph nodes of inguinal region and lower limb
|
|
20066
|
Anaplastic large cell lymphoma
|
|
20067
|
Anaplastic large cell lymphoma, spleen
|
|
20068
|
Anaplastic large cell lymphoma, lymph nodes of multiple sites
|
|
20070
|
Large cell lymphoma, unspecified site, extranodal and solid organ sites
|
|
20071
|
Large cell lymphoma, lymph nodes of head, face, and neck
|
|
20072
|
Large cell lymphoma, intrathoracic lymph nodes
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|
20073
|
Large cell lymphoma, intra-abdominal lymph nodes
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|
20074
|
Large cell lymphoma, lymph nodes of axilla and upper limb
|
|
20075
|
Large cell lymphoma, lymph nodes of inguinal region and lower limb
|
|
20076
|
Large cell lymphoma, intrapelvic lymph nodes
|
|
20077
|
Large cell lymphoma, spleen
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|
20078
|
Large cell lymphoma, lymph nodes of multiple sites
|
|
20270
|
Peripheral T cell lymphoma, unspecified site, extranodal and solid organ sites
|
|
20271
|
Peripheral T cell lymphoma, lymph nodes of head, face, and neck
|
|
20272
|
Peripheral T cell lymphoma, intrathoracic lymph nodes
|
|
20273
|
Peripheral T cell lymphoma, intra-abdominal lymph nodes
|
|
20274
|
Peripheral T cell lymphoma, lymph nodes of axilla and upper limb
|
|
20275
|
Peripheral T cell lymphoma, lymph nodes of inguinal region and lower limb
|
|
20276
|
Peripheral T cell lymphoma, intrapelvic lymph nodes
|
|
20277
|
Peripheral T cell lymphoma, spleen
|
|
20278
|
Peripheral T cell lymphoma, lymph nodes of multiple sites
|
|
20511
|
Myeloid leukemia, chronic, in remission
|
|
2775
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Mucopolysaccharidosis
|
|
27912
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Wiskott-Aldrich syndrome
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|
2792
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Combined immunity deficiency
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|
28241
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Sickle-cell thalassemia without crisis
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|
28242
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Sickle-cell thalassemia with crisis
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|
28249
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Other thalassemia
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|
28260
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Sickle-cell disease, unspecified
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|
28261
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HB-SS disease without crisis
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|
28262
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HB-SS disease with crisis
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|
28263
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Sickle-cell/HB-C disease without crisis
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|
28264
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Sickle-cell/HB-C disease with crisis
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|
28268
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Other sickle-cell disease without crisis
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|
28269
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Other sickle-cell disease with crisis
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|
28409
|
Other constitutional aplastic anemia
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|
28481
|
Red cell aplasia (acquired) (adult) (with thymoma)
|
|
28489
|
Other specified aplastic anemias
|
|
2849
|
Aplastic anemia, unspecified
|
|
75652
|
Osteopetrosis
|
|
V1562
|
Family history of malignant neoplasm, bladder
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Stem cell transplants for clients with the diagnosis of 27912, Wiskott-Aldrich syndrome, may be approved using a 6/6 antigen matched, HLA molecular typing negative related or unrelated donor. Stem cell transplant for clients with the diagnosis of 2792, Combined immunity deficiency, may be approved using a 4, 5, or 6 of 6 antigen matched, HLA molecular typing negative related or unrelated donor.
Stem cell transplants for clients with diagnosis codes 28260, 28261, 28262, 28263, and 28269 may be approved for clients 16 years of age and younger who have documented homozygous sickle cell anemia, a HLA-identical related, and one or more of the following complications:
•Previous (cerebrovascular accident [CVA]).
•Recurrent chest syndrome.
•Recurrent vaso-occlusive (pain) crises.
•Chronic transfusions resulting in red blood cell allo-immunization.
Stem cell transplants for clients with diagnosis codes 2840 and 2849 may be approved when their platelets are <20x109/L, granulocytes are < 0.5x109/L, and reticulocytes are <1 percent when corrected for hematocrit, and there is a 6/6 antigen matched related or unrelated donor or a 5/6 antigen matched family member donor for patients failing antithymocyte globulin therapy.
Autologous or Allogenic Transplants
In addition to the diagnosis codes listed in the autologous or allogenic tables above, stem cell transplants may also be approved for clients with a diagnosis of neoplasm (diagnosis codes 1400 through 2089) listed in the current International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
Autologous and allogenic stem cell transplants may be reimbursed for clients with Hodgkin's disease who are in an advanced disease state with failure of conventional therapy.
Stem cell transplants may be considered for other conditions if documentation provides clinical evidence of the efficacy of stem cell transplant for the condition.
Coverage is limited to an initial transplant and one subsequent retransplant due to rejection, for a total of two transplants per lifetime regardless of payer. The subsequent transplant must be prior authorized separately from the initial transplant.
Physician Reimbursement
Physicians may be reimbursed the lower of the billed amount or the amount allowed by the Texas Medicaid Program.
If approved, a letter with the authorization number is sent to the physician (when applicable) and to the hospital where the procedure is to be performed. This authorization number must be placed in Block 23 of the CMS-1500 claim form.
When the procedures are performed on an emergency basis, deadlines and requirements supporting documentation (e.g., the admitting history and physical, pathology, and consultation reports) must accompany the claim.
Refer to: Section 24.3.12.5, "Emergency Services," on page 24-33 for the definition of emergency. Note: A benefit of up to 60 additional inpatient days may be granted to a client, to begin the date of hospital admission for an approved stem cell transplant. Donor costs must be included on the client's inpatient hospital claim for the transplant and are included in the $200,000 limit for the transplant maximum amount.
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