Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A59175 (Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A59175: Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (Billing and Coding, effective 2026-03-05)
- Covered ICD-10-CM codes
- 352
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C81.00 | — |
| C81.01 | — |
| C81.02 | — |
| C81.03 | — |
| C81.04 | — |
| C81.05 | — |
| C81.06 | — |
| C81.07 | — |
| C81.08 | — |
| C81.09 | — |
| C81.10 | — |
| C81.11 | — |
| C81.12 | — |
| C81.13 | — |
| C81.14 | — |
| C81.15 | — |
| C81.16 | — |
| C81.17 | — |
| C81.18 | — |
| C81.19 | — |
| C81.20 | — |
| C81.21 | — |
| C81.22 | — |
| C81.23 | — |
Procedure codes: 38240.
Coverage indications, limitations and medical necessity
Per NCD 110.12 Stem cell transplantation is a process in which s tem cells are harvested from a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion to replace diseased and malignant processes which have undergone therapeutic treatment and ablation. Autologous S tem Cell Transplantation (AuSCT) is a technique for restoring stem cell s using the patient's own previously stored cells. Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a procedure in which a portion of a healthy donor's stem cells or bone marrow is obtained and prepared for intravenous infusion to accomplish the hematopoietic restoration for those individual unable to utilize their own cells. AuSCT must be used to affect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies and disease.
The Centers for Medicare & Medicaid Services (CMS) has clarified per NCD 110.23 "that bone marrow and peripheral blood stem cell transplantation is a process which includes mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells associated with the administration of high dose chemotherapy or radiotherapy prior to the actual transplant. When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are included in coverage and reimbursement per Medicare allowed fee schedule. When bone marrow or peripheral blood stem cell transplantation is non-covered, none of the steps are covered.”
NCD 110.23 Stem Cell Transplantation includes coverage for allogeneic transplantation when meeting requirement criteria outlined within the Coverage Determination. Please refer to NCD 110.23 for those provisions.
• Leukemia, leukemia in remission
• Aplastic Anemia
• Severe Combined Immunodeficiency disease (SCID)
• Wiskott-Aldrich Syndrome
Allogeneic-HSCT is covered only for Medicare beneficiaries with the following indications when participating in an approved prospective clinical study meeting specific criteria under the Coverage with Evidence Development (CED) paradigm. For details pertaining to coverage criteria please refer to NCD 110.23.
• Myelodysplastic Syndrome
• Multiple myeloma limited to beneficiaries with Durie-Salmon Stage II or III multiple myeloma, or International Staging System (ISS) Stage II or Stage III multiple myeloma
• Myelofibrosis (MF) limited to beneficiaries with Dynamic International Prognostic Scoring System (DIPSSplus) intermediate-2 or High primary or secondary MF; or
• Sickle cell disease (SCD) limited to beneficiaries with severe, symptomatic SCD who participate in an approved prospective clinical study meeting specific criteria under the CED paradigm. (Please refer to CMS, Publication 100-03, Medicare National Coverage Determinations Manual (NCD) , Chapter 1, Part 2, §110.23)
Per the NCD, “Coverage of all other indications for stem cell transplantation not otherwise specified above as covered or non-covered will be made by local Medicare Administrative Contractors under sections 1862(a)(1)(A)."
It is the intention of this Local Coverage Determination to formally notify Medicare enrolled providers of Noridian Medicare’s coverage and allowance for reimbursement of services related to Allogeneic Stem Cell Transplantation in compliance with NCD 110.23. Covered indications for allogeneic stem cell transplant of hemopoietic cells extracted from healthy donor matched peripheral blood and/or bone marrow for infusion as treatment of primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphoma, B-cell or T-cell origin, is limited to Medicare beneficiaries for whom the primary disease is refractory to standard-of-care treatment or for those whose disease has relapsed and are without alternative potentially curative options.
Documentation to support medical necessity as well as the appropriateness of the choice of therapy must be retained in the patient’s chart and made available to Medicare on request. It must include all elements mandated by NCD 110.23 for Stem Cell Transplantation as well as in-depth patient history and physical exam, the nature and severity of the disease process, previous therapeutic interventions, disease course and response to therapy, rationale for choice of therapy, and evidence of patient (and family) education of risk and benefit inherent to the intervention. Risk assessment as well as documentation of concomitant disease and psychosocial factors affecting outcome are suggested as components of the in-depth patient assessment.
Summary of evidence (opening)
Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) has been increasingly used for a variety of hematologic neoplasms and non-malignant marrow disorders. Eligibility for Allo-HSCT varies among institutions and is considered on a case-by-case basis, dependent upon a risk-benefit assessment, and the needs of the patient. 6
Historically Allogeneic-HSCT has been offered to patients having exhausted all other treatment modalities. Current practice has shifted decision criteria to an assessment of patient anticipated benefit relative to other treatment options for refractory Hodgkins and non-Hodgkins lymphoma. For some lymphoma, literature and data support an expected outcome superior to other treatment options. 6
The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for stem cell transplant without exclusion of the disease entities considered in this Policy. Noridian considers Allogeneic Stem Cell Transplantation (Allo-HSCT) combined with marrow ablative chemotherapy or radiation therapy, medically reasonable and necessary for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphoma with B-cell or T-cell origin, for whom there are no other curative intent options. There are no age-related restrictions to coverage.
Multiple other disorders are under investigation as part of clinical trials and remain unaffected by this determination. Refer to NCD NCD 310.1 Routine Costs in Clinical Trials for coverage criteria. Those disorders specifically excluded from coverage by NCD 110.23 remain noncovered.
The contractor cites 9 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2023-03-05
- Current revision effective
- 2026-03-05
- MCD version
- 7
The contractor lists 2 National Coverage Determinations as related: NCD 110.23 Stem Cell Transplantation (Formerly 110.8.1), NCD 310.1 Routine Costs in Clinical Trials. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Other related documents: A59325 (Response to Comments), A59326 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L39396 cover?
Per NCD 110.12 Stem cell transplantation is a process in which s tem cells are harvested from a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion to replace diseased and malignant processes which have undergone therapeutic treatment and ablation. Autologous S tem Cell Transplantation (AuSCT) is a technique for restoring stem cell s using the patient's own… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L39396 apply to?
Noridian Healthcare Solutions, LLC applies it to Medicare claims in AK, AS, AZ, CA, CNMI, GU, HI, ID, MT, ND, NF, NV, OR, SD, SF, UT, WA, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L39396?
The companion billing and coding article A59175 lists 352 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L39396?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.