Aetna considers compatibility testing of prospective donors who are close family members (first-degree relatives (i.e., parents, siblings and children) or second degree relatives (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling)) and harvesting and short-term storage of peripheral stem cells or bone marrow from the identified donor medically necessary when an allogeneic bone marrow or peripheral stem cell transplant is authorized by Aetna.
Aetna considers umbilical cord blood stem cells an acceptable alternative to conventional bone marrow or peripheral stem cells for allogeneic transplant.
Aetna considers medically necessary the short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment when there is a match. Note: The harvesting, freezing and/or storing umbilical cord blood of non-diseased persons for possible future use is not considered treatment of disease or injury. Such use is not related to the person’s current medical care.
See also the following CPBs related to bone marrow and peripheral stem cell transplantation:
According to the American Academy of Pediatrics (2007), cord blood transplantation has been shown to be curative in patients with a variety of serious diseases. Physicians should be familiar with the rationale for cord blood banking and with the types of cord blood banking programs available. Physicians consulted by prospective parents about cord blood banking can provide the following information:
Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant's cord blood (i.e., pre-malignant changes in stem cells). Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood. Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation.
Cord blood donation should be encouraged when the cord blood is stored in a bank for public use. Parents should recognize that genetic (e.g., chromosomal abnormalities) and infectious disease testing is performed on the cord blood and that if abnormalities are identified, they will be notified. Parents should also be informed that the cord blood banked in a public program may not be accessible for future private use.
Eapen and colleagues (2010) stated that umbilical-cord blood (UCB) is increasingly considered as an alternative to peripheral blood progenitor cells (PBPCs) or bone marrow, especially when an human leukocyte antigen (HLA)-matched adult unrelated donor is not available. These investigators aimed to determine the optimal role of UCB grafts in transplantation for adults with acute leukemia, and to establish whether current graft-selection practices are appropriate. They used Cox regression to retrospectively compare leukemia-free survival and other outcomes for UCB, PBPC, and bone marrow transplantation in patients aged 16 years or over who underwent a transplant for acute leukemia. Data were available on 1,525 patients transplanted between 2002 and 2006. A total of 165 received UCB, 888 received PBPCs, and 472 received bone marrow. Umbilical-cord blood units were matched at HLA-A and HLA-B at antigen level, and HLA-DRB1 at allele level (n = 10), or mis-matched at 1 antigen (n = 40) or 2 antigens (n = 115). Peripheral blood progenitor cells and bone-marrow grafts from unrelated adult donors were matched for allele-level HLA-A, HLA-B, HLA-C, and HLA-DRB1 (n = 632 and n = 332, respectively), or mis-matched at 1 locus (n = 256 and n = 140, respectively). Leukemia-free survival in patients after UCB transplantation was comparable with that after 8/8 and 7/8 allele-matched PBPC or bone-marrow transplantation. However, transplant-related mortality was higher after UCB transplantation than after 8/8 allele-matched PBPC recipients (hazard ratio [HR] 1.62, 95 % confidence interval [CI]: 1.18 to 2.23; p = 0.003) or bone-marrow transplantation (HR 1.69, 95 % CI: 1.19 to 2.39; p = 0.003). Grades 2 to 4 acute and chronic graft-versus-host disease (GVHD) were lower in UCB recipients compared with allele-matched PBPC (HR 0.57, 95 % CI: 0.42 to 0.77; p = 0.002 and HR 0.38, 95 % CI: 0.27 to 0.53; p = 0.003, respectively), while the incidence of chronic, but not acute GVHD, was lower after UCB than after 8/8 allele-matched bone-marrow transplantation (HR 0.63, 95 % CI: 0.44 to 0.90; p = 0.01). These data support the use of UCB for adults with acute leukemia when there is no HLA-matched unrelated adult donor available, and when a transplant is needed urgently.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes covered if selection criteria are met:|
|38204||Management of recipient hematopoietic progenitor cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic|
|38207||Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage|
|38208||thawing of previously frozen harvest, without washing|
|38209||thawing of previously frozen harvest, with washing|
|38210||specific cell depletion within harvest, T-cell depletion|
|38211||tumor cell depletion|
|38212||red blood cell removal|
|38214||plasma (volume) depletion|
|38215||Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer|
|38230||Bone marrow harvesting for transplantation|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|59012||Cordocentesis (intrauterine), any method|
|86813||HLA typing; A, B, or C, multiple antigens|
|86817||DR/DQ, multiple antigens|
|86821||lymphocyte culture, mixed (MLC)|
|86822||lymphocyte culture, primed (PLC)|
|86920||Compatibility test each unit; immediate spin technique|
|Other CPT codes related to the CPB:|
|83890 - 83914||Molecular diagnostics|
|Modifiers 4A - 4Z||Histocompatibility/Blood Typing/Identity/Microsatellite|
|HCPCS codes covered if selection criteria are met:|
|G0364||Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service|
|S2140||Cord blood harvesting for transplantation, allogeneic|
|S2142||Cord blood-derived stem-cell transplantation, allogeneic|
|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; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre-and post-transplant care in the global definition|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|C00.0 - C75.9||Malignant neoplasm|
|Z52.001||Unspecified donor, stem cells [prospective donors who are close family members (first-degree relatives or second degree relatives)]|
|Z52.3||Bone marrow donor [prospective donors who are close family members (first-degree relatives or second degree relatives)]|