Obtain prior authorization for listed transplant procedure and related codes

Prior authorization is required for the transplant-related CPT and HCPCS codes listed in the policy when the medical necessity selection criteria are met; submit PA for the specific procedure codes (e.g., stem cell harvesting, transplantation, HLA typing, chemotherapy administration) included in the policy when requesting coverage.

• Covered CPT/HCPCS codes are enumerated in the policy and require authorization when selection criteria are met (see CPT/HCPCS lists).

Indicate transplant type and conditioning regimen on authorization

Specify the intended transplant type (autologous vs allogeneic) and the conditioning regimen (for example, high-dose melphalan or HDC with TBI) on authorization requests because expected hospitalization needs and length of stay vary by regimen.

• High-dose melphalan (140–200 mg/m2) may be outpatient; regimens including TBI typically require ~30 days hospitalization — document regimen to inform authorization.

Request authorizations consistent with recommended sequencing of cellular therapies

When requesting authorization, align timing and sequencing of cellular therapies with clinical recommendations: auto‑HCT is endorsed as frontline consolidation while allo‑HCT and CAR‑T in the frontline setting are recommended only in clinical trials — reflect these sequencing considerations in requests and trial exceptions where applicable.

• ASTCT endorses auto‑HCT consolidation for newly diagnosed MM and advises allo‑HCT and CAR‑T in frontline only within clinical trials.

Document sequencing context for BCMA‑targeted therapies; no explicit PA sequencing rules provided

Be aware the policy discusses sequencing of BCMA‑targeted agents (e.g., prior ADC/BsAb exposure before cilta‑cel) but does not establish explicit prior‑authorization or code‑level sequencing rules; include clinical rationale and trial history in the submission when sequencing is relevant.

• CARTITUDE‑2 data show responses after prior non‑cellular anti‑BCMA exposure, but sample sizes and prior‑treatment details were limited — document prior BCMA therapies and timing.

Follow plan resources for prior‑authorization submission details

The policy excerpt does not provide detailed plan-specific prior authorization procedures or forms; consult the plan’s Clinical Policy Bulletin Notes and other plan resources for submission instructions and PA contact information.

• Users are directed to Clinical Policy Bulletin Notes and plan resources for administrative PA details.

No step‑therapy algorithm specified in this excerpt

No formal step‑therapy sequencing is specified in this portion of the policy; the policy states that step therapy is not applicable here.

• When considering sequencing of therapies (including cellular therapies), the policy provides clinical guidance but does not mandate a step‑therapy algorithm.

Consider salvage autologous HCT per expert consensus criteria

Salvage autologous HCT should be considered for transplantation‑eligible patients who relapse after primary therapy that did not include an autologous HCT, and for patients who relapsed after prior autologous HCT if the initial remission duration was greater than 18 months.

• Expert consensus: salvage autologous HCT is standard for transplant‑eligible patients relapsing after non‑ASCT primary therapy.
• Salvage autologous HCT appropriate when prior autologous HCT remission duration >18 months.

Provider guidance placeholder — consult policy citations

No additional provider‑action text is specified in the excerpt for this placeholder; refer to the policy and cited references for further clinical guidance as needed.

Submit documentation that member meets transplant center eligibility criteria

Document that the member meets the transplanting institution’s written eligibility or protocol criteria, including adequate major organ function and absence of significant comorbid conditions; when applicable, document early relapse timing (<24 months) after prior autologous HCT.

• Selection criteria include absence of significant comorbidities and adequate major organ function per transplant center evaluation.
• Early relapse (<24 months) after prior autologous HCT must be documented when applicable.

Document stem cell mobilization and collection details (apheresis, regimen, yields)

Include detailed documentation of stem cell mobilization and collection procedures in the record and authorization submission — note use of apheresis catheter placement, number of apheresis procedures (typically 5–10), mobilization regimen (e.g., cyclophosphamide and/or GM‑CSF), and collected yields.

• Apheresis catheter insertion and number of outpatient apheresis procedures should be recorded.
• Mobilization protocols and whether inpatient hospitalization was required (e.g., high‑dose cyclophosphamide) should be documented.

Provide pre‑transplant fitness, frailty, comorbidity, and renal function documentation

Provide pre‑transplant clinical documentation of patient fitness, functional status, frailty assessment, comorbidity profile, and renal function (including dialysis dependence when applicable) to support candidacy and expected outcomes.

• Guidelines recommend assessing candidacy based on fitness/frailty/comorbidity rather than kidney function alone; document dialysis status and prior hematologic response if combined kidney transplant considered.

Document prior BCMA therapies and circulating plasma cell status for sequencing and risk assessment

When sequencing therapies or considering cellular therapies after BCMA‑targeted agents, document prior BCMA‑targeted therapies and timing; record presence or absence of circulating plasma cells (CPCs), since CPCs ≥5% are identified as a high‑risk feature relevant to risk stratification.

• Document prior exposure to ADCs, BsAbs, CAR‑T, including dates and response when available.
• Record CPC assessment (threshold ≥5% flagged by NCCN) to inform risk and sequencing decisions.

No further documentation specifics in this excerpt — use plan resources for forms

This excerpt does not list additional specific documentation requirements beyond those above; consult the full Clinical Policy Bulletin Notes and plan resources for any plan‑specific forms or checklists.

• Policy provides links to additional information and glossary; use plan resources for administrative documentation requirements.

Recognize exclusion conditions that may lead to denial — confirm organ function and compliance

Transplant requests may be denied when members have inadequate cardiac, pulmonary, or hepatic function, another life‑limiting cancer or a cancer that may become life‑threatening with immunosuppression, or psychiatric disease that would interfere with compliance; verify and document organ function and comorbidity status to avoid denial.

• Exclusion criteria listed include inadequate cardiac, pulmonary, or hepatic function and psychiatric disease that impairs compliance.
• Presence of another life‑limiting cancer that could worsen with immunosuppression is an exclusion.

Document and address historical adverse risk factors that could affect authorization

Be alert that historically identified adverse risk factors — including high transplant‑related mortality, inadequate organ function, and heavy prior therapy — were associated with worse outcomes and may influence eligibility decisions; document how the patient’s risk profile differs from historical exclusion criteria.

• Trials historically excluded patients with inadequate cardiac, renal, pulmonary, or hepatic function or with heavy prior therapy.

Justify tandem transplant requests with selection criteria or trial context due to TRM and mixed evidence

Tandem (double) autologous transplantation may increase treatment‑related mortality and has inconsistent evidence for survival benefit across pooled randomized trials; when requesting tandem transplants, document specific clinical indications, trial participation, or selection criteria that justify tandem strategy.

• Attal et al. showed benefit in selected patients, but meta-analysis found no consistent OS/EFS benefit and increased TRM with tandem AHCT — provide selection rationale.

Background material does not list explicit authorization/denial triggers — support requests with required documentation

No explicit authorization or denial triggers are provided in these background chunks; interpret clinical recommendations in the policy and support authorization requests with the documentation described herein.

• Background sections summarize evidence and recommendations but do not list additional administrative triggers.

Policy excerpt informational — follow plan procedures for coverage decisions

This excerpt does not specify any additional provider actions; note the Clinical Policy Bulletin is informational and users should follow plan procedures for benefit determination.

• Aetna Clinical Policy Bulletins assist in administering benefits but do not replace clinical judgment or plan‑specific administrative rules.