(Medicare Claims Processing Manual)

Effective for services performed on or after March 15, 2005,  when recognized clinical risk factors are employed to select  patients  for transplantation, high-dose melphalan  (HDM)  together  with autologous stem cell transplantation (HDM/AuSCT) is  reasonable and necessary for Medicare beneficiaries of any age group for the treatment of primary amyloid light chain (AL) amyloidosis, ICD-10- CM codes E85.4, E85.81, E85.9, and E85.89  who  meet the following  criteria:   Amyloid  deposition in 2 or fewer  organs; and,  Cardiac left ventricular  ejection  fraction  (EF) greater  than  45%.  90.2.1 - HCPCS and Diagnosis Coding for Stem Cell Transplantation - ICD-10-CM Applicable  (Rev.  11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21)  ICD-10 is applicable to services on and after the implementation of ICD-.   For services provided use the appropriate code from  the ICD -10 CM  codes the table  below..  See 90.2 for a list of covered  conditions   ICD-10 Description  C91.00  Acute  lymphoblastic  leukemia  not having  achieved  remission  C91.01  Acute  lymphoblastic  leukemia,  in remission  C91.02  Acute  lymphoblastic  leukemia,  in relapse  C91.10  Chronic  lymphocytic  leukemia  of B-cell type not having  achieved  remission  C91.11  Chronic  lymphocytic  leukemia  of B-cell type in remission  C91.12  Chronic  lymphocytic  leukemia  of B-cell type in relapse    C91.30  Prolymphocytic  leukemia  of B-cell type not having  achieved  remission  C91.31  Prolymphocytic  leukemia  of B-cell type,  in remission  C91.32  Prolymphocytic  leukemia  of B-cell type,  in relapse  C91.50  Adult  T-cell lymphoma/leukemia (HTLV -1-associated)  not having  achieved remission  C91.51  Adult  T-cell lymphoma/leukemia  (HTLV -1-associated),  in remission  C91.52  Adult  T-cell lymphoma/leukemia (HTLV -1-associated),  in relapse  C91.60  Prolymphocytic  leukemia  of T-cell type not having achieved  remission  C91.61  Prolymphocytic  leukemia  of T-cell type,  in remission  C91.62  Prolymphocytic  leukemia  of T-cell type,  in relapse  C91.90  Lymphoid  leukemia,  unspecified  not having  achieved  remission  C91.91  Lymphoid  leukemia,  unspecified,  in remission  C91.92  Lymphoid  leukemia,  unspecified,  in relapse  C91.A0  Mature  B-cell leukemia  Burkitt -type not having  achieved  remission  C91.A1  Mature  B-cell leukemia Burkitt -type,  in remission  C91.A2  Mature  B-cell leukemia Burkitt -type,  in relapse  C91.Z0  Other  lymphoid  leukemia  not having  achieved  remission  C91.Z1  Other  lymphoid  leukemia,  in remission  C91.Z2  Other  lymphoid  leukemia,  in relapse  C92.00  Acute  myeloblastic  leukemia,  not having  achieved remission  C92.01  Acute  myeloblastic  leukemia,  in remission  C92.02  Acute  myeloblastic  leukemia,  in relapse  C92.10  Chronic  myeloid  leukemia,  BCR/ABL -positive,  not having  achieved  remission  C92.11  Chronic  myeloid  leukemia,  BCR/ABL -positive,  in remission  C92.12  Chronic  myeloid  leukemia,  BCR/ABL -positive,  in relapse  C92.20  Atypical  chronic  myeloid  leukemia,  BCR/ABL -negative,  not having  achieved  remission  C92.21  Atypical  chronic  myeloid leukemia,  BCR/ABL -negative,  in remission  C92.22  Atypical  chronic  myeloid  leukemia,  BCR/ABL -negative,  in relapse  C92.30  Myeloid  sarcoma,  not having  achieved  remission  C92.31  Myeloid  sarcoma,  in remission  C92.32  Myeloid  sarcoma,  in relapse  C92.40  Acute  promyelocytic  leukemia,  not having achieved  remission  C92.41  Acute  promyelocytic  leukemia,  in remission  C92.42  Acute  promyelocytic  leukemia,  in relapse  C92.50  Acute  myelomonocytic  leukemia,  not having  achieved  remission  C92.51  Acute  myelomonocytic  leukemia,  in remission  C92.52  Acute  myelomonocytic  leukemia,  in relapse  C92.60  Acute  myeloid  leukemia with  11q23 -abnormality  not having  achieved  remission  C92.61  Acute  myeloid  leukemia with  11q23 -abnormality  in remission  C92.62  Acute  myeloid  leukemia  with 11q23 -abnormality  in relapse  C92.90  Myeloid  leukemia,  unspecified,  not having  achieved  remission  C92.91  Myeloid  leukemia,  unspecified  in remission  C92.92  Myeloid  leukemia,  unspecified  in relapse  C92.A0  Acute  myeloid  leukemia  with multilineage  dysplasia,  not having  achieved  remission  C92.A1  Acute  myeloid  leukemia with  multilineage  dysplasia,  in remission  C92 A2  At  l id lk i  ith ltili  d li  i l    C92.Z0  Other  myeloid  leukemia  not having  achieved  remission  C92.Z1  Other  myeloid  leukemia,  in remission  C92.Z2  Other  myeloid  leukemia, in  relapse  C93.00  Acute  monoblastic/monocytic  leukemia,  not having  achieved  remission  C93.01  Acute  monoblastic/monocytic  leukemia,  in remission  C93.02  Acute  monoblastic/monocytic  leukemia,  in relapse  C93.10  Chronic  myelomonocytic leukemia  not having  achieved  remission  C93.11  Chronic  myelomonocytic leukemia,  in remission  C93.12  Chronic  myelomonocytic leukemia,  in relapse  C93.30  Juvenile  myelomonocytic leukemia,  not having  achieved  remission  C93.31  Juvenile  myelomonocytic  leukemia,  in remission  C93.32  Juvenile  myelomonocytic leukemia,  in relapse  C93.90  Monocytic  leukemia,  unspecified,  not having  achieved  remission  C93.91  Monocytic  leukemia,  unspecified  in remission  C93.92  Monocytic  leukemia,  unspecified  in relapse  C93.Z0  Other  monocytic  leukemia,  not having achieved  remission  C93.Z1  Other  monocytic  leukemia,  in remission  C93.Z2  Other  monocytic  leukemia,  in relapse  C94.00  Acute  erythroid  leukemia,  not having  achieved  remission  C94.01  Acute  erythroid  leukemia,  in remission  C94.02  Acute  erythroid  leukemia, in  relapse  C94.20  Acute  megakaryoblastic  leukemia  not having  achieved  remission  C94.21  Acute  megakaryoblastic  leukemia,  in remission  C94.22  Acute  megakaryoblastic  leukemia,  in relapse  C94.30  Mast  cell leukemia  not having  achieved  remission  C94.31  Mast  cell leukemia,  in remission  C94.32  Mast  cell leukemia,  in relapse  C94.80  Other  specified  leukemias  not having achieved  remission  C94.81  Other  specified  leukemias,  in remission  C94.82  Other  specified  leukemias,  in relapse  C95.00  Acute  leukemia  of unspecified  cell type not having  achieved  remission  C95.01  Acute  leukemia  of unspecified  cell type, in  remission  C95.02  Acute  leukemia  of unspecified  cell type,  in relapse  C95.10  Chronic  leukemia  of unspecified  cell type not having  achieved  remission  C95.11  Chronic  leukemia  of unspecified  cell type, in  remission  C95.12  Chronic  leukemia  of unspecified  cell type,  in relapse  C95.90  Leukemia,  unspecified  not having  achieved  remission  C95.91  Leukemia,  unspecified,  in remission  C95.92  Leukemia,  unspecified,  in relapse  D45 Polycythemia  vera  III. For the treatment  of aplastic  anemia;  see table below  for ICD-10- CM codes)       If ICD- 10-CM is applicable,  the following  ranges  of ICD- 10-CM codes  are also covered  for AuSCT:    Resistant  non-Hodgkins  lymphomas, ICD-10-CM diagnosis codes C82.01- C85.29, C85.81-  C86.6, C96.4, and C96.Z -C96.9.   Tandem  transplantation  (multiple  rounds  of autologous  stem cell transplantation) for patients with multiple  myeloma, ICD -10-CM codes C90.00, C90.01, C90.02 and D47.Z9   NOTE:  The  following conditions are  not covered:   Acute leukemia  not in remission   Chronic  granulocytic  leukemia   Solid  tumors  (other  than neuroblastoma)   Multiple  myeloma   For Medicare beneficiaries  age 64 or  older, all  forms  of amyloidosis, primary  and non-primary   Non-primary  amyloidosis   Also coverage for conditions other than those specifically designated as  covered in 90.2 or specifically designated as non -covered in this section  or in 90.3will  be at the discretion  of the  individual  contractor.  ICD-10 Description  D60.0  Chronic  acquired  pure red cell aplasia  D60.1  Transient  acquired  pure red cell aplasia  D60.8  Other  acquired  pure red cell aplasias  D60.9  Acquired  pure red cell  aplasia,  unspecified  D61.01  Constitutional  (pure)  red blood  cell aplasia  D61.09  Other  constitutional  aplastic  anemia  D61.1  Drug -induced aplastic  anemia  D61.2  Aplastic  anemia  due to other  external agents  D61.3  Idiopathic  aplastic  anemia  D61.810  Antineoplastic  chemotherapy  induced pancytopenia  D61.811  Other  drug-induced  pancytopenia  D61.818  Other  pancytopenia  D61.82  Myelophthisis  D61.89  Other  specified  aplastic anemias  and other  bone  marrow failure  syndromes  D61.9  Aplastic  anemia,  unspecified   90.3 - Non-Covered Conditions (Rev.11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21)  Autologous  stem  cell transplantation  is not covered  for the following conditions: