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 A59259 (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.
A59259: 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 2024-11-28)
- Covered ICD-10-CM codes
- 380
- 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
Stem Cell Transplantation is a process in which stem cells are harvested from a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion. Autologous Stem Cell Transplantation (AuSCT) is a technique for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies.
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. Hematopoietic stem cells are multi-potent cells that give rise to all the blood cell types; these stem cells form blood and immune cells. A hematopoietic stem cell is a cell isolated from blood or bone marrow that can renew itself, differentiate to a variety of specialized cells, can mobilize out of the bone marrow into circulating blood, and can undergo programmed cell death, called apoptosis - a process by which cells that are unneeded or detrimental will self-destruct.
The Centers for Medicare & Medicaid Services (CMS) has clarified 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 and 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.
NCD 110.23 Stem Cell Transplantation covers allo-HSCT for the following conditions, when reasonable and necessary:
• Leukemia, leukemia in remission
• Aplastic Anemia
• Severe Combined Immunodeficiency disease (SCID)
• Wiskott-Aldrich Syndrome
• Myelodysplastic Syndrome
Allo-HSCT is covered for Medicare beneficiaries with the following indications only when participating in approved prospective clinical studies meeting specific criteria under the Coverage with Evidence Development (CED) paradigm:
• Multiple myeloma limited to beneficiaries with Durie-Salmon Stage II or III disease, or International Staging System (ISS) Stage II or Stage III disease
• Myelofibrosis (MF) with Dynamic International Prognostic Scoring System (DIPSSplus) intermediate-2 or High primary or secondary disease; or
• Sickle cell disease (SCD) that is severe and symptomatic
(Please refer to CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §110.23 Stem Cell Transplantation)
Per the NCD, all other indications for stem cell transplantation not otherwise noted as covered or non-covered remain at local Medicare Administrative Contractor (MAC) discretion.
This policy describes additional locally covered indications for allo-HSCT for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphomas with B-cell or T-cell origin that are medically necessary in patients for whom there are no other curative intent options.
Documentation to support the reasonable and necessary nature of allo-HSCTs must speak to the serious illness of the patient, the reasons why the patient is considered to have relapsed or refractory disease, relevant clinical contextual information such as age, frailty, performance status, cardiopulmonary function, any associated organ dysfunction that could impact complications or recovery, screening for infectious diseases that could impact transplant care, nutritional status and patient specific psychosocial and financial support structures. Risk assessment scoring, such as the European Society for Blood and Bone Marrow Transplantation (EBMT) or the HCT Comorbidity Index (HCT-CI), should be strongly considered and in the case of any nationally covered indications per NCD 110.23 would of course be required.
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
Although historically allo-HCT was offered to patients who had exhausted all other treatment modalities, currently the decision to perform a transplant is dependent upon an assessment if the transplant will offer an outcome superior to other treatment options. 6
The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for SCT, the details of which will not be fully repeated within this policy. This policy describes additional locally covered indications for allogeneic stem cell for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphomas with B-cell or T-cell origin, for whom there are no other curative intent options, and are medically necessary.
Multiple other disorders are under investigation as part of clinical trials and are not covered unless the clinical trial meets the criteria of NCD 310.1 Routine Costs in Clinical Trials.
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
- 2023-02-12
- Current revision effective
- 2024-12-26
- Last reviewed by the contractor
- 2024-10-24
- 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: A59306 (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 Wisconsin Physicians Service Insurance Corporation 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 L39477 cover?
Stem Cell Transplantation is a process in which stem cells are harvested from a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion. Autologous Stem Cell Transplantation (AuSCT) is a technique for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of… 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 L39477 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, 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 L39477?
The companion billing and coding article A59259 lists 380 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 L39477?
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.