06/06/2022
| This version of the policy will become effective 06/06/2022.
The policy was updated to communicate the Medically Necessary coverage position of the FDA-approved indication for the Prophylaxis of Acute Graft-Versus-Host Disease (aGVHD).
Additionally, immune checkpoint inhibitor-related autoimmune-like toxicity indication was revised from suspected myocarditis, to myocarditis.
The following ICD CM codes have been added to this policy:
D89.811 Chronic graft-versus-host disease D89.812 Acute on chronic graft-versus-host disease I40.8 Other acute myocarditis I40.9 Acute myocarditis, unspecified
Z94.84 Stem cell transplantation status Z29.8 Encounter for other specified prophylactic measures
The following ICD CM codes have been deleted from this policy, due to specificity/laterality: M05.019, M05.029, M05.039, M05.049, M05.059, M05.069, M05.079, M05.119, M05.129, M05.139, M05.149, M05.159, M05.169, M05.179, M05.219, M05.229, M05.239, M05.249, M05.259, M05.269, M05.279, M05.319, M05.329, M05.339, M05.349, M05.359, M05.369, M05.379, M05.419, M05.429, M05.439, M05.449, M05.459, M05.469, M05.479, M05.519, M05.529, M05.539, M05.549, M05.559, M05.569, M05.579, M05.619, M05.629, M05.639, M05.649, M05.659, M05.669, M05.679, M05.719, M05.729, M05.739, M05.749, M05.759, M05.769, M05.779, M05.819, M05.829, M05.839, M05.849, M05.859, M05.869, M05.879, M06.019, M06.029, M06.039, M06.049, M06.059, M06.069, M06.079,
M06.819, M06.829, M06.839, M06.849, M06.859, M06.869, M06.879 |