Anthem Blue Cross Blue Shield of California policy
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products is a public Anthem Blue Cross Blue Shield of California policy (policy TRANS.00035). It lists 27 CPT or HCPCS codes, 21 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- TRANS.00035
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 00011 | Not listed | Policies naming 00011 | |
| 00035 | Not listed | Policies naming 00035 | |
| 00110 | Not listed | Policies naming 00110 | |
| 00132 | Not listed | Policies naming 00132 | |
| 00155 | Not listed | Policies naming 00155 | |
| 0232T | On the list | Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed | Policies naming 0232T |
| 0263T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one le.g., including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest | Policies naming 0263T |
| 0264T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one le.g., including ultrasound guidance, if performed; complete procedure excluding unilateral or bilateral bone marrow harvest | Policies naming 0264T |
| 0265T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one le.g., including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy | Policies naming 0265T |
| 0481T | On the list | Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed | Policies naming 0481T |
| 0748T | On the list | Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (e.g., removal of setons, fistula curettage, closure of internal openings) | Policies naming 0748T |
| 1092T | On the list | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; into chondral defect, open | Policies naming 1092T |
| 1093T | On the list | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; into a chondral or osteochondral defect, arthroscopic | Policies naming 1093T |
| 1094T | On the list | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; each additional acellular scaffold implantation | Policies naming 1094T |
| 1095T | On the list | Harvesting and processing of autologous bone marrow aspirate concentrate (BMAC), with application onto scaffold or injection into anatomical recipient site (eg, subchondral bone, joint space, chondral lesion), including imaging guidance, when performed, for therapeutic musculoskeletal treatment, excluding spinal procedures | Policies naming 1095T |
| 17999 | On the list | Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen] or [when specified as permanent hair removal by laser] or [when specified as implantation of biologic implants for soft tissue reinforcement in tissues other than breast and trunk] or [when specified as aesthetic flat chest closure or chest wall reconstruction after breast surgery] or [when specified as laser treatment of onychomycosis] or [when specified as percutaneous ultrasound ablation of subcutaneous tissue] or [when specified as application of prademagene zamikeracel (Zevaskyn) genetically engineered autologous cell therapy] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 17999 |
| 20999 | On the list | Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound for pain palliation for bone metastases] or [No specific code for surgery using Coblation technology] or [when specified as radiofrequency or pulsed radiofrequency treatment of trigger points] or [when specified as percutaneous ultrasonic ablation of soft tissue] or [when specified as harvesting and injection of bone marrow aspirate concentrate or harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 20999 |
| 33999 | On the list | Unlisted procedure, cardiac surgery [when specified as percutaneous transmyocardial revascularization] or [when specified as transmyocardial transcatheter closure of ventricular septal defect, with implant, including cardiopulmonary bypass if performed] or [when specified as transcatheter replacement of tricuspid heart valve] or [when specified as autologous cell therapy for damaged myocardium, including harvesting and preparation of cells] or [when specified as use of a portable normothermic organ perfusion system for heart transplantation] | Policies naming 33999 |
| 38205 | On the list | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic | Policies naming 38205 |
| 38206 | On the list | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous | Policies naming 38206 |
| 38230 | On the list | Bone marrow harvesting for transplantation; allogeneic | Policies naming 38230 |
| 38232 | On the list | Bone marrow harvesting for transplantation; autologous | Policies naming 38232 |
| 38999 | On the list | Unlisted procedure, hemic or lymphatic system [when specified as use of an ex-vivo expansion of cord blood stem cell product such as omidubicel (Omisirge)] or [when specified as bone marrow cell therapy or stem cell therapy such as IM, IV or IA for peripheral vascular disease] | Policies naming 38999 |
| 64999 | On the list | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 64999 |
| G0460 | On the list | Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all other preparatory procedures, administration and dressings, per treatment | Policies naming G0460 |
| G0465 | On the list | Autologous platelet rich plasma (PRP) or other blood-derived products for diabetic chronic wounds/ulcers, using an FDA- cleared device for this indication (includes as applicable administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | Policies naming G0465 |
| P9020 | Not listed | Policies naming P9020 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list