Active LCD for Irradiated Blood Products (L28533)

LCD for Irradiated Blood Products (L28533)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

Number	Type	State(s)
00130	FI	IN
00131	FI	IL
00160	FI	KY
00332	FI	OH
00450	FI	WI
00452	FI	MI
00453	FI	VA, WV
00630	Carrier	IN
00660	Carrier	KY
13101	MAC	CT – Part A
13102	MAC	CT – Part B
13201	MAC	NY – Part A
13202	MAC	NY – Part B
13282	MAC	NY- Part B
13292	MAC	NY – Part B

Contractor Type

Carrier

Fiscal Intermediary

MAC-Part A

MAC-Part B

LCD Information

LCD ID Number

L28533

LCD Title

Irradiated Blood Products

Contractor's Determination Number

L28533

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR, Section 410.10 Medical and other health services: Included services
42 CFR, Section 410.29 Limitations on drugs and biologicals
42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

Federal Register, Vol. 59, No. 29, February 11, 1994, pages 6570-6579, is the Partial Hospitalization Services in Community Mental Health Centers Interim Final Rule.

CMS Publications:

CMS Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3:

20.5 - Blood Deductibles (Part A and Part B)

20.5.1 - Part A Blood Deductible

20.5.2 - Part B Blood Deductible

20.5.3 - Items Subject to Blood Deductibles

20.5.4 - Obligations of the Beneficiary to Pay for or Replace Deductible Blood

20.5.4.1 - Replacement of Blood

CMS Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5:

10.1.4 – Definitions: Blood

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1:

10 - Covered Inpatient Hospital Services Covered Under Part A

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

50 - Drugs and Biologicals

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1: Part 2 (Sections 90 – 160.25):

110.7 - Blood Transfusions

110.8 - Blood Platelet Transfusions

CMS Publications 100-04, Medicare Claims Processing Manual, Chapter 4:

231 - Billing and Payment for Blood and Blood Products Under the Hospital Outpatient Prospective Payment System (OPPS)

CMS Publications 100-04, Medicare Claims Processing Manual, Chapter 17:

Drugs and Biologicals

Primary Geographic Jurisdiction

Number	Type	State(s)
00130	FI	IN
00131	FI	IL
00160	FI	KY
00332	FI	OH
00450	FI	WI
00452	FI	MI
00453	FI	VA, WV
00630	Carrier	IN
00660	Carrier	KY
13101	MAC	CT – Part A
13102	MAC	CT – Part B
13201	MAC	NY – Part A
13202	MAC	NY – Part B
13282	MAC	NY- Part B
13292	MAC	NY – Part B

Oversight Region

Region I, II, III, V

Original Determination Effective Date

For services performed on or after 01/01/2009

Original Determination Ending Date

Not applicable

Revision Effective Date

06/05/2009

Revision Ending Date

Not applicable

Indications and Limitations of Coverage and/or Medical Necessity

Abstract:

The purpose of transfusing irradiated blood products is to prevent transfusion-associated graft versus host disease (TAGVHD). TAGVHD is a rare complication of transfusion that results from transfusion of immunocompetent T cells capable of bonding to and initiating an immune response against recipient antigens. The most susceptible patient groups are those who are severely immunocompromised or are the recipients of directed donations from first-degree relatives. TAGVHD can be prevented by gamma irradiation of cellular blood components (i.e., red cells, platelets, granulocytes). ¹Medicare will not cover the extra costs associated with irradiation of blood products solely to allow directed donations if acceptable non-directed blood products are available.

Indications:

Irradiated blood products are indicated for the following conditions:

Selected immunoincompetent recipients. (e.g., patients with congenital immunodeficiency who exhibit defective cell mediated immunity, DiGeorge syndrome, Wiscott Aldrich syndrome, severe combined immunity deficiency (SCID).²
Bone marrow transplant recipients and peripheral blood stem cell transplant candidates. ³
"Intrauterine transfusions and exchange transfusions for newborns that have had an intrauterine transfusion."⁴
Patients receiving HLA-matched platelets or granulated transfusions.⁵
Patients with hematologic malignancy including Hodgkin's disease, lymphoma, leukemia and myelodysplastic syndromes ⁶
Low birthweight neonates (<1200 grams) during the first four months of life⁷
Patients with aplastic anemia or unexplained cytopenias, particularly if treated with antilymphocyte or antithymocyte globulin ⁸
Non-hematologic cancer patients treated with multiagent chemotherapy or combined chemo/radiotherapy within the past year ⁹
Infants < 1 year of age with unexplained illness such as growth failure, persistent diarrhea, recurrent or unusual infections, etc. ¹⁰
Patients receiving purine analogs
Infants less than 6 months of age.

Limitations:

Irradiated cellular products are not indicated for:

•    Cancer treatment without multiagent or combined chemotherapy and radiation therapy¹¹

•    Patients with HIV infection ¹²

•    Solid organ transplant patients¹³

•    Full term neonates without other risks

LCD Category
Pathology/Laboratory

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier and fiscal intermediary predecessors of National Government Services (AdminaStar Federal, Anthem Health Plans of New Hampshire, Associated Hospital Service, Empire Medicare Services, Group Health Incorporated (GHI), HealthNow, First Coast Service Options (CT) and United Government Services).

For claims submitted to the fiscal intermediary: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.

Bill type codes only apply to providers who bill these services to the fiscal intermediary. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

Notice to beneficiaries related to discharge and coverage notification, as described in CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 60 – 60.1.1, applies.

Hospitals have been instructed to provide Hospital-Issued Notices of Noncoverage (HINNs) to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it is:

Not medically necessary;
Not delivered in the most appropriate setting; or
Is custodial in nature.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for irradiated blood products as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

Coverage Topic

Lab Services

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11x	Hospital-inpatient (including Part A)
12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility
73x	Clinic-independent provider based FQHC (eff 10/91)
83x	Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

0250	Pharmacy-general classification
0300	Laboratory-general classification
0380	Blood-general classification
088X	Miscellaneous dialysis-general classification

CPT/HCPCS Codes

P9032	PLATELETS, IRRADIATED, EACH UNIT
P9033	PLATELETS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
P9036	PLATELETS, PHERESIS, IRRADIATED, EACH UNIT
P9037	PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
P9038	RED BLOOD CELLS, IRRADIATED, EACH UNIT
P9040	RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
P9053	PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT
P9056	WHOLE BLOOD, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
P9057	RED BLOOD CELLS, FROZEN/DEGLYCEROLIZED/WASHED, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
P9058	RED BLOOD CELLS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT

ICD-9 Codes that Support Medical Necessity

It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Claims for multiagent chemotherapy must be coded with both V58.89 "Other specified aftercare" and a cancer diagnosis code (ICD-9-CM range 200.30 – 208.91) from the list below.

200.30	MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.31	MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK
200.32	MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES
200.33	MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES
200.34	MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.35	MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.36	MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES
200.37	MARGINAL ZONE LYMPHOMA, SPLEEN
200.38	MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40	MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.41	MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.42	MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.43	MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.44	MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.45	MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.46	MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.47	MANTLE CELL LYMPHOMA, SPLEEN
200.48	MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.51	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.52	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES
200.53	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.54	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.55	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.56	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES
200.57	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN
200.58	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60	ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.61	ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.62	ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.63	ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.64	ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.65	ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.66	ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.67	ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN
200.68	ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70	LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.71	LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.72	LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.73	LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.74	LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.75	LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.76	LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.77	LARGE CELL LYMPHOMA, SPLEEN
200.78	LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
201.00	HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE
201.01	HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.02	HODGKIN'S PARAGRANULOMA INVOLVING INTRATHORACIC LYMPH NODES
201.03	HODGKIN'S PARAGRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.04	HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.05	HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.06	HODGKIN'S PARAGRANULOMA INVOLVING INTRAPELVIC LYMPH NODES
201.07	HODGKIN'S PARAGRANULOMA INVOLVING SPLEEN
201.08	HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.10	HODGKIN'S GRANULOMA UNSPECIFIED SITE
201.11	HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.12	HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES
201.13	HODGKIN'S GRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.14	HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.15	HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.16	HODGKIN'S GRANULOMA INVOLVING INTRAPELVIC LYMPH NODES
201.17	HODGKIN'S GRANULOMA INVOLVING SPLEEN
201.18	HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.20	HODGKIN'S SARCOMA UNSPECIFIED SITE
201.21	HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.22	HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES
201.23	HODGKIN'S SARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.24	HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.25	HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.26	HODGKIN'S SARCOMA INVOLVING INTRAPELVIC LYMPH NODES
201.27	HODGKIN'S SARCOMA INVOLVING SPLEEN
201.28	HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.40	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE
201.41	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.42	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES
201.43	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.44	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.45	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.46	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES
201.47	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN
201.48	HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES
201.50	HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE
201.51	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.52	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES
201.53	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.54	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.55	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.56	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES
201.57	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN
201.58	HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
201.60	HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE
201.61	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.62	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES
201.63	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.64	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.65	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.66	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES
201.67	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN
201.68	HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES
201.70	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE
201.71	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.72	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES
201.73	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.74	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.75	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.76	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES
201.77	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN
201.78	HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES
201.90	HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE
201.91	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
201.92	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES
201.93	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES
201.94	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
201.95	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
201.96	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES
201.97	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN
201.98	HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00	NODULAR LYMPHOMA UNSPECIFIED SITE
202.01	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.02	NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
202.03	NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.04	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.05	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.06	NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
202.07	NODULAR LYMPHOMA INVOLVING SPLEEN
202.08	NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20	SEZARY'S DISEASE UNSPECIFIED SITE
202.21	SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.22	SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.23	SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.24	SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.25	SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.26	SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.27	SEZARY'S DISEASE INVOLVING SPLEEN
202.28	SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30	MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE
202.31	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.32	MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.33	MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.34	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.35	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.36	MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.37	MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN
202.38	MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40	LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE
202.41	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.42	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.43	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.44	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
202.45	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.46	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.47	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN
202.48	LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50	LETTERER-SIWE DISEASE UNSPECIFIED SITE
202.51	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.52	LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.53	LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.54	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.55	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.56	LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.57	LETTERER-SIWE DISEASE INVOLVING SPLEEN
202.58	LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60	MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE
202.61	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.62	MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES
202.63	MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.64	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.65	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.66	MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES
202.67	MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN
202.68	MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70	PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
202.71	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
202.72	PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
202.73	PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
202.74	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
202.75	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.76	PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
202.77	PERIPHERAL T CELL LYMPHOMA, SPLEEN
202.78	PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80	OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
202.81	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.82	OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES
202.83	OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.84	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.85	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.86	OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES
202.87	OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN
202.88	OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.90	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE
202.91	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.92	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES
202.93	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.94	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.95	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.96	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES
202.97	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN
202.98	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.10	PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11	PLASMA CELL LEUKEMIA IN REMISSION
203.80	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81	OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
204.00	ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.01	LYMPHOID LEUKEMIA ACUTE IN REMISSION
204.10	CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.11	LYMPHOID LEUKEMIA CHRONIC IN REMISSION
204.20	SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.21	LYMPHOID LEUKEMIA SUBACUTE IN REMISSION
204.80	OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.81	OTHER LYMPHOID LEUKEMIA IN REMISSION
204.90	UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.91	UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION
205.00	ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.01	MYELOID LEUKEMIA ACUTE IN REMISSION
205.10	CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.11	MYELOID LEUKEMIA CHRONIC IN REMISSION
205.20	SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.21	MYELOID LEUKEMIA SUBACUTE IN REMISSION
205.30	MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.31	MYELOID SARCOMA IN REMISSION
205.80	OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.81	OTHER MYELOID LEUKEMIA IN REMISSION
205.90	UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.91	UNSPECIFIED MYELOID LEUKEMIA IN REMISSION
206.00	ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.01	MONOCYTIC LEUKEMIA ACUTE IN REMISSION
206.10	CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.11	MONOCYTIC LEUKEMIA CHRONIC IN REMISSION
206.20	SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.21	MONOCYTIC LEUKEMIA SUBACUTE IN REMISSION
206.80	OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.81	OTHER MONOCYTIC LEUKEMIA IN REMISSION
206.90	UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.91	UNSPECIFIED MONOCYTIC LEUKEMIA IN REMISSION
207.00	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.01	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION
207.10	CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.11	CHRONIC ERYTHREMIA IN REMISSION
207.20	MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.21	MEGAKARYOCYTIC LEUKEMIA IN REMISSION
207.80	OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.81	OTHER SPECIFIED LEUKEMIA IN REMISSION
208.00	ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.01	LEUKEMIA OF UNSPECIFIED CELL TYPE ACUTE IN REMISSION
208.10	CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.11	LEUKEMIA OF UNSPECIFIED CELL TYPE CHRONIC IN REMISSION
208.20	SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.21	LEUKEMIA OF UNSPECIFIED CELL TYPE SUBACUTE IN REMISSION
208.80	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.81	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE IN REMISSION
208.90	UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.91	UNSPECIFIED LEUKEMIA IN REMISSION
238.72	LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS
238.73	HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS
238.74	MYELODYSPLASTIC SYNDROME WITH 5Q DELETION
238.75	MYELODYSPLASTIC SYNDROME, UNSPECIFIED
238.76	MYELOFIBROSIS WITH MYELOID METAPLASIA
238.77	POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD)
238.79	OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES
279.10	IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED
279.11	DIGEORGE'S SYNDROME
279.12	WISKOTT-ALDRICH SYNDROME
279.13	NEZELOF'S SYNDROME
279.2	COMBINED IMMUNITY DEFICIENCY
284.1	PANCYTOPENIA
284.2	MYELOPHTHISIS
284.89	OTHER SPECIFIED APLASTIC ANEMIAS
284.9	APLASTIC ANEMIA UNSPECIFIED
765.01	DISORDERS RELATING TO EXTREME IMMATURITY OF INFANT LESS THAN 500 GRAMS
765.02	DISORDERS RELATING TO EXTREME IMMATURITY OF INFANT 500-749 GRAMS
765.03	DISORDERS RELATING TO EXTREME IMMATURITY OF INFANT 750-999 GRAMS
765.04	DISORDERS RELATING TO EXTREME IMMATURITY OF INFANT 1000-1249 GRAMS
765.11	DISORDERS RELATING TO OTHER PRETERM INFANTS LESS THAN 500 GRAMS
765.12	DISORDERS RELATING TO OTHER PRETERM INFANTS 500-749 GRAMS
765.13	DISORDERS RELATING TO OTHER PRETERM INFANTS 750-999 GRAMS
765.14	DISORDERS RELATING TO OTHER PRETERM INFANTS 1000-1249 GRAMS
773.0	HEMOLYTIC DISEASE OF FETUS OR NEWBORN DUE TO RH ISOIMMUNIZATION
773.1	HEMOLYTIC DISEASE OF FETUS OR NEWBORN DUE TO ABO ISOIMMUNIZATION
773.2	HEMOLYTIC DISEASE OF FETUS OR NEWBORN DUE TO OTHER AND UNSPECIFIED ISOIMMUNIZATION
773.3	HYDROPS FETALIS DUE TO ISOIMMUNIZATION
773.4	KERNICTERUS OF FETUS OR NEWBORN DUE TO ISOIMMUNIZATION
774.0	PERINATAL JAUNDICE FROM HEREDITARY HEMOLYTIC ANEMIAS
774.1	PERINATAL JAUNDICE FROM OTHER EXCESSIVE HEMOLYSIS
774.2	NEONATAL JAUNDICE ASSOCIATED WITH PRETERM DELIVERY
774.30	NEONATAL JAUNDICE DUE TO DELAYED CONJUGATION CAUSE UNSPECIFIED
774.31	NEONATAL JAUNDICE DUE TO DELAYED CONJUGATION IN DISEASES CLASSIFIED ELSEWHERE
774.39	OTHER NEONATAL JAUNDICE DUE TO DELAYED CONJUGATION FROM OTHER CAUSES
774.4	PERINATAL JAUNDICE DUE TO HEPATOCELLULAR DAMAGE
774.5	PERINATAL JAUNDICE FROM OTHER CAUSES
774.6	UNSPECIFIED FETAL AND NEONATAL JAUNDICE
774.7	KERNICTERUS OF FETUS OR NEWBORN NOT DUE TO ISOIMMUNIZATION
V15.3	PERSONAL HISTORY OF IRRADIATION PRESENTING HAZARDS TO HEALTH
V21.31	LOW BIRTH WEIGHT STATUS LESS THAN 500 GRAMS
V21.32	LOW BIRTH WEIGHT STATUS 500-999 GRAMS
V21.33	LOW BIRTH WEIGHT STATUS 1000-1499 GRAMS
V42.81	BONE MARROW REPLACED BY TRANSPLANT
V42.82	PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT
V58.89	OTHER SPECIFIED AFTERCARE

Diagnoses that Support Medical Necessity

Not applicable

ICD-9 Codes that DO NOT Support Medical Necessity

Not applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Not applicable

Diagnoses that DO NOT Support Medical Necessity

Not applicable

General Information

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Appendices

Not applicable

Utilization Guidelines

Not applicable

Sources of Information and Basis for Decision

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

^{2 through 13} Oregon Health and Science University Department of Pathology, Division of Laboratory Medicine Transfusion Manual May 2005. Available at: http://www.oshu.edu/pathology/transman/index.html. Accessed September 30, 2005.

^{1 through 4} Triulzi D.J. Institute for Transfusion Medicine transfusion Medicine Update. September 1992. Available at: http://www.itmx.org/archive/tmu9-92.htm. Accessed September 30, 2005

^{2 through 10, 12 and 13} University of Iowa Handbook for Blood Center Services. Available at: http://www.medicine.iowa.edu/path_handbook/Appendix/BloodCenter/blood_ctr_serv.
Accessed December 19, 2005

Other Sources:

American Association of Blood Banks Circular of Information for the use of Human Blood and Blood Components July 2002.

America's Blood Centers ABC Blood Bulletin Irradiation of Blood Products vol.2, no.1 May 1999. Available at: http://www.americasblood.org/index.cfm?fuseaction=display.showPage&Page1-=131.
Accessed September 30, 2005.

American Red Cross 7/30/2003 Practice Guidelines for Blood Transfusion: A compilation from recent Peer-Reviewed Literature – (May 2002)
Available at: http://www.redcross.org/services/biomed/profess/pgbtscreen.pdf . Accessed September 30, 2005

Gersmsheimer T. Blood Component Therapy 2005. Pugent Sound Blood Center Program revised 4/20/2005.

Huh Y.O. Leucocyte Reduced, Cytomegalovirus-Screened, and Irradiated Blood Components: Indications and Controversies. Current Issues in Transfusion Medicine April-June 1993. Available at: http://www3.mdanderson.org/ . Accessed September 30, 2005.

Puget Sound Blood Center Blood Components Reference Manual. Available at: http://www.psbc.org/bcrm/04_irradiated_blood.htm. Accessed September 30, 2005.

Triulzi D.J.Transfusion Support in Solid Organ Transplantation. Institute for Transfusion Medicine Transfusion Medicine Update. April 2001. Available at: http://www.itmx.org/ tmu2001/tmu4-2001.htm.

University of Michigan Blood Bank Manual Chapter 4 Blood Components.
Available at: http://www.pathology.med.umich.edu/bloodbankmanual/bbch_4/index.html. Accessed September 30, 2005

Advisory Committee Meeting Notes

Carrier Advisory Committee Meeting Date(s):

Connecticut: 09/16/2008
Indiana: 09/22/2008
Kentucky: 09/25/2008
New York: 09/10/2008

This coverage determination does not reflect the sole opinion of the contractor or contractor Medical Director. Although the final decision rests with the contractor, this determination was developed consultation with representatives from Advisory Committee members and/or from various state and local provider organizations.

Start Date of Comment Period

09/02/2008

End Date of Comment Period

10/16/2008

Start Date of Notice Period

11/17/2008

Revision History Number

Not applicable

Revision History Explanation

06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this LCD as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this LCD as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

Reason for Change

Not applicable

Last Reviewed On Date

11/17/2008

Related Documents

Article(s)
A48036 - Irradiated Blood Products – Supplemental Instructions Article

LCD Attachments

Irradiated Blood Products - Comment and Response (224,634 bytes)