CMSNational Coverage Determination (NCD)

CMS Granulocyte Transfusions Form


Granulocyte Transfusions

Indications

(824170) Does the patient suffer from granulocytopenia with fewer than 500 granulocytes/mm3 whole blood? 
(824171) Does the patient have granulocytopenia with evidence of gram negative sepsis? 
(824172) Is the patient with granulocytopenia febrile and has local progressive infections unresponsive to appropriate antibiotic therapy, thought to be due to gram negative organisms? 

Effective Date

01/01/2066

Last Reviewed

NA

Original Document

  Reference



Granulocyte transfusions to patients suffering from severe infection and granulocytopenia are a covered service under Medicare. Granulocytopenia is usually identified as fewer than 500 granulocytes/mm3 whole blood. Accepted indications for granulocyte transfusions include:

  • Granulocytopenia with evidence of gram negative sepsis; and
  • Granulocytopenia in febrile patients with local progressive infections unresponsive to appropriate antibiotic therapy, thought to be due to gram negative organisms.