Currentpriority healthPolicy N/A

UMBILICAL CORD BLOOD TESTING AND STORAGE

Defines medical necessity criteria for compatibility testing and storage of umbilical cord blood for allogeneic transplant purposes, applicable to various Priority Health products and subject to member-specific benefits and related Stem Cell/Bone Marrow Transplantation policy (#91066).

Policy Summary

Payerpriority health

PolicyUMBILICAL CORD BLOOD TESTING AND STORAGE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 4, 2015

Next Review Date

Key ActionWhen requesting compatibility testing or storage, providers must demonstrate an accepted indication for an allogeneic transplant per medical policy #91066 and document relationship and member status.

POLICY UPDATE CHANGES

No material changes to clinical or coverage criteria

3Medically necessary scenarios listed

1Not medically necessary scenario

2S-codes non-payable for Medicaid/Medicare

Coverage summary

Scope: Defines medical necessity criteria for compatibility testing and storage of umbilical cord blood for allogeneic transplant purposes, applicable to various Priority Health products and subject to member-specific benefits and the related Stem Cell/Bone Marrow Transplantation medical policy (#91066).

Medical necessity criteria

Compatibility testing — Medically necessary

Compatibility testing of umbilical cord blood is medically necessary if ALL of the following apply:

ALL of the following

An accepted indication for an allogeneic transplant exists; see the Stem Cell/Bone Marrow Transplantation (#91066) medical policy for coverage criteria.
The intended recipient of the transplant is a first-degree relative (parent, sibling) of the infant.
The intended recipient of the transplant is a current member.

Storage of umbilical cord blood — Medically necessary

Storage of umbilical cord blood is medically necessary if ALL of the following apply:

ALL of the following

A clinically acceptable match is present.
An accepted indication for an allogeneic transplant exists; see the Stem Cell/Bone Marrow Transplantation (#91066) medical policy for coverage criteria.
The intended recipient of the transplant is a current member.

Not medically necessary

The following is considered not medically necessary:

ALL of the following

Random testing, freezing and/or storage of umbilical cord blood for unspecified possible future use (private 'biologic insurance').

Relevant codes

No prior authorization codes / Unlisted procedures (informational)CPT|HCPCS

59899	Unlisted procedure, maternity care and delivery
38999	Unlisted procedure, hemic or lymphatic system
59000	Amniocentesis; diagnostic

Umbilical cord blood testing and related procedures (covered when criteria met)CPTCovered

59012	Cordocentesis (intrauterine), any method
59015	Chorionic villus sampling, any method
86812	HLA typing; A, B, or C (eg, A10, B7, B27), single antigen
86813	HLA typing; A, B, or C, multiple antigens
86816	HLA typing; DR/DQ, single antigen
86817	HLA typing; DR/DQ, multiple antigens
86821	HLA typing; lymphocyte culture, mixed (MLC)
88240	Cryopreservation, freezing and storage of cells, each cell line
88241	Thawing and expansion of frozen cells, each aliquot

Auth required (see medical policy 91066 Stem Cell or Bone Marrow Transplantation)CPTCovered

38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor

S codes (not payable for Priority Health Medicaid or Medicare)HCPCSNot Covered

S2140	Cord blood harvesting for transplantation, allogeneic
S2142	Cord blood-derived stem-cell transplantation, allogeneic

Required provider actions

Documentation Required

Reference allogeneic transplant indication

When requesting compatibility testing or storage, providers must demonstrate an accepted indication for an allogeneic transplant per the Stem Cell/Bone Marrow Transplantation medical policy #91066.

Documentation Required

Confirm intended recipient relationship and membership

Provider must document that the intended recipient is a first-degree relative (parent, sibling) for testing and that the intended recipient is a current member for testing and storage. Ensure documentation specifically notes the first-degree relationship and current membership status.

Document that the recipient is a first-degree relative (parent or sibling) and is a current Priority Health member.

Prior Authorization

Authorization for certain transplant preparation procedures

Prior authorization is required for the procedures listed under the 'Auth required' section and per medical policy #91066. Follow the Priority Health Provider Manual for the prior authorization process when submitting requests for these procedures.

38205
38207
38209
See medical policy #91066 and Priority Health Provider Manual for PA process.

Billing Rule

S-code non-payable for Medicaid/Medicare

S2140 and S2142 are designated as not payable for Priority Health Medicaid or Medicare members; these HCPCS S-codes should not be billed for those lines of business.

S2140
S2142
Not payable for Priority Health Medicaid or Medicare members.

Background and definitions

Background: Umbilical cord blood stem cells can be used as an alternative to a conventional allogeneic bone marrow transplant for a variety of marrow-based disorders (for example, leukemia, aplastic anemia, and certain inherited metabolic disorders).

Professional society stance: Storage of umbilical cord blood for private use in the future as 'biologic insurance' is not recommended by the American Society of Transplantation and Cellular Therapy (formerly ASBMT), the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics.

Compatibility testing: Compatibility testing may be performed on chorionic villous sampling (CVS) specimens, amniocytes obtained by amniocentesis, or on the cord blood itself.

Term	Definition
First-degree relative
Parent or sibling of the infant.
Clinically acceptable match
Match adequate for intended allogeneic transplant per Stem Cell/Bone Marrow Transplantation policy #91066.

Policy Summary

Payerpriority health

PolicyUMBILICAL CORD BLOOD TESTING AND STORAGE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 4, 2015

Next Review Date

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