When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
J1442 Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram
J1447 Injection, tbo-filgrastim, 1 microgram
J2505 Injection, pegfilgrastim, 6 mg
J2562 Injection, plerixafor, 1 mg
J2820 Injection, sargramostim (GM-CSF), 50 mcg
Q5101 Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram
Q5110 Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram
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
S9537 Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
Policy: 07.00.20f:Routine Costs Associated with Qualifying Clinical Trials
Policy: 08.01.32:Pegfilgrastim (Neulasta®)