Obtain prior authorization for listed transplant procedure and billing codes

Prior authorization is required for the listed transplant and related CPT/HCPCS/ICD-10 codes when the policy selection criteria are met. Covered CPT/HCPCS codes include 38205, 38206, 38230, 38232, 38240, 38241, 86813, 86817, 86821 and HCPCS S2150; covered ICD-10 diagnoses include C90.00–C90.02, C90.10–C90.12, D47.Z9, and E85.0–E85.9. Submit documentation showing the member meets the applicable institutional or policy selection criteria with the prior authorization request.

• Include evidence that the transplanting institution’s written eligibility criteria are met or, if none, that the member meets all policy selection criteria.
• Attach relevant diagnosis codes (e.g., C90.* for multiple myeloma) and the procedure codes being requested.

Prefer allogeneic HCT within a clinical trial; document eligibility

When allogeneic HCT is considered, perform it in the context of a clinical trial when possible and document trial enrollment or rationale; allogeneic HCT is appropriate for eligible patients with early relapse (<24 months) after prior autologous HCT or high‑risk disease features.

• Document trial name/identifier or explain why trial enrollment is not feasible.
• If no protocol exists, supply documentation that the member has adequate major organ function and meets the early‑relapse or high‑risk criteria per policy.

Document prior lines of therapy and anti‑BCMA exposure for CAR‑T sequencing

For consideration of CAR‑T or other cellular therapies after multiple prior lines, confirm and document prior lines of systemic therapy and any prior exposure to BCMA‑targeting non‑cellular agents (e.g., ADCs or BsAbs) on the authorization or treatment request.

• Include a therapy history listing agents/classes used and dates of exposure.
• If prior anti‑BCMA therapy was given, document type (ADC, BsAb) and treatment dates to support sequencing decisions for cilta‑cel or other CAR‑T products.

Policy history noted — follow payer-specific PA submission process

Policy history and review links are provided in the document but specific procedural steps for prior authorization are not detailed in these chunks; use the prior authorization requirement and code list in the policy and submit supporting clinical documentation as described elsewhere in the policy.

• Refer to the policy’s prior authorization portal or payer instructions for submission procedures and forms.
• Include clinical rationale and all required selection criteria documentation with the request.

Document induction therapy and response before transplant

Patients typically undergo induction therapy before high‑dose chemotherapy and transplant; document induction regimen and response prior to authorization for HDC and transplant.

• Common induction examples historically include VAD or melphalan/prednisone; record regimen, dates, and best response.
• Ensure documentation of disease status at time of transplant evaluation (e.g., remission status).

Record timing of autologous SCT and induction/mobilization details

Early versus delayed autologous SCT have shown comparable overall survival when modern IMiD‑based induction and early stem cell mobilization are used; document timing of harvest/transplant and induction regimen when relevant to sequencing decisions.

• Indicate whether SCT was performed early (≤12 months) or delayed (>12 months) and provide dates of harvest and transplant.
• If delayed, include reason for delay and any interim therapies.

Align therapy sequencing with ASTCT recommendations and document rationale

Follow ASTCT sequencing guidance: auto‑HCT consolidation remains a standard option for newly diagnosed MM; allo‑HCT and CAR‑T are recommended in trials or later lines—document why chosen sequencing aligns with these recommendations.

• If CAR‑T or allo‑HCT is proposed frontline, document justification and trial enrollment as ASTCT does not recommend frontline use outside trials.
• For RRMM, document number of prior lines of therapy if proposing CAR‑T (ASTCT recommended for patients with ≥4 prior lines).

No payer step‑therapy rules detailed here — provide full therapy history

The policy does not specify step therapy requirements in this section; do not assume mandated step edits—submit clinical rationale and the member’s complete treatment history with authorization requests.

• If payer-specific step edits exist, follow those external requirements; otherwise provide full prior‑therapy documentation to support clinical decision‑making.

Confirm institution’s written eligibility or document all policy selection criteria

Transplanting institution’s written eligibility criteria or protocol eligibility criteria must be met; if institutional criteria are absent, include documentation that the member meets all policy selection criteria (no significant comorbidities, limited prior alkylator therapy, adequate organ function, and not indolent/smoldering disease or MGUS).

• Attach the transplant center’s eligibility checklist or protocol.
• If relying on policy criteria, document each required element: comorbidity status, prior chemo/radiation limits, organ function assessment, and disease classification.

Document stem cell collection quantity and plan to permit two transplants

Collect and document sufficient hematopoietic stem cells early to permit two transplants when clinically appropriate; include stem cell collection yields and storage information in the patient's record and authorization materials.

• Record number of collections, total CD34+ cells collected, and planned storage for a second transplant if indicated.
• If a second transplant is anticipated, document the planned timing (e.g., within 6 months for tandem transplants) or rationale for deferred use.

Provide detailed prior therapy history including BCMA‑targeting exposures

When considering cellular therapy sequencing, document prior lines of therapy and any prior exposure to BCMA‑targeting agents (ADCs or BsAbs) to support eligibility and expected response assessments for CAR‑T (cilta‑cel) or other cellular products.

• List prior systemic therapies with dates and responses, and specify any anti‑BCMA non‑cellular treatments with dates.
• Include available response data (MRD status, PFS on prior therapy) to inform sequencing decisions.

Use administrative/contact resources; include clinical and institutional documentation with requests

Administrative and contact information is provided in the policy’s additional information and history sections; specific documentation checklists for authorization are not included here, so ensure submission of clinical notes, tumor/status assessments, and institution eligibility documentation.

• Use the payer’s authorization portal or contact lines shown in policy materials for submission questions.
• Attach clinical evaluation notes, organ function testing, and transplant center eligibility forms to support requests.

Exclusion criteria that may trigger denial — document organ function and comorbid conditions

Do not authorize transplant for members who have inadequate cardiac, renal, pulmonary, or hepatic function, another life‑limiting cancer, or psychiatric disease that would interfere with compliance; these exclusion criteria can lead to denial.

• Provide current cardiac, renal, hepatic, and pulmonary evaluation results to demonstrate adequacy.
• If psychiatric disease or another life‑limiting cancer is present, include detailed assessment and rationale for proceeding if seeking exception.

Document poor outcomes in resistant relapse when proposing transplant

Recognize that patients in resistant relapse historically had high early mortality and low complete remission rates after HDC‑ABMT; document disease status and expected benefit when proposing transplant in resistant relapse.

• If member has resistant relapse, include prior response history and justification for expected benefit from transplant.
• Be aware that historical data showed 36% early mortality and no complete remissions in resistant relapse cohorts, which may influence coverage decisions.

Document outpatient ASCT candidacy: functional status and caregiver support

For outpatient ASCT, select patients stringently and document adequate functional status, reliable caregiving support, and psychosocial readiness; insufficient selection may increase complications and readmissions and can affect coverage decisions.

• Include documentation of functional status (performance scale), named caregiver availability, and psychosocial assessment.
• If proposing outpatient ASCT, describe the outpatient care model and planned monitoring/support to mitigate readmission risk.

No additional explicit denial triggers listed here — verify current policy criteria

This section of the policy does not list additional explicit denial triggers; however, policy history and review dates are provided and may affect eligibility determinations—ensure current policy criteria are met and documented.

• Confirm that documentation meets the most recent policy version and review date.
• If there is uncertainty, consult payer administrative contacts noted in the policy.

Demonstrate adequate major organ function per transplant evaluation

Adequate major organ function must be demonstrated based on the transplanting institution's evaluation prior to approval for autologous or allogeneic transplant.

• Policy requirement: “The member has adequate major organ function based on the transplant institution's evaluation.”

Evaluate disease status and collect stem cells early

Experts recommend early stem cell collection to permit two transplants; transplant eligibility evaluation should include disease status, prior therapies, and organ function.

• Expert committee: collect enough hematopoietic stem cells early to perform two transplants.
• Transplant evaluation should document remission duration, cytogenetic/high‑risk features, and prior therapies.

Document hematologic remission and renal function for combined kidney+HCT candidates

For combined kidney transplant and HCT candidates, documentation should include assessment of hematologic remission status, renal function, and plans for coordinating immunosuppression across both transplants.

• Combined KT/HCT cases require documentation of remission status and renal function; plans for immunosuppression management are necessary due to complexity.

Policy history provided — no additional evaluation steps specified here

Policy history and review links are present in the document; the cited excerpts do not specify specific pre‑transplant evaluation steps beyond institutional evaluation expectations.

• Policy includes last review and effective dates; explicit pre‑transplant evaluation steps are not provided in these administrative excerpts.

Use institution's written eligibility or protocol criteria for transplant eligibility

The transplanting institution's written eligibility criteria or protocol eligibility criteria are expected to be used to determine eligibility for autologous, allogeneic, non‑myeloablative, and tandem transplants.

• Policy states coverage when the institution's written eligibility or protocol criteria are met.
• NDMP criteria referenced for unrelated donor selection in tandem/allogeneic context.

No specific center accreditation or volume requirements specified in excerpts

Not specified in the provided excerpts: center‑level operational requirements such as accreditation, minimum volume, or specific infrastructure are not detailed; centers are described in relation to outpatient/inpatient models and clinical trials.

• Cited studies reference variable outpatient models and clinical trial participation but do not define center accreditation or volume thresholds.

Center operational models referenced, but no extra requirements specified

Not specified in the provided excerpts: no additional center requirements (beyond using institutional protocols and ability to run outpatient models or trials) are detailed.

• Centers are described as implementing outpatient ASCT models and participating in trials; specific infrastructure expectations are not listed here.

Combined transplant programs acknowledged; no center standards listed in excerpts

Not specified in the provided excerpts: centers conducting combined kidney/HCT or specialized tolerance protocols are noted but explicit center eligibility criteria are not provided here.

• Combined transplant approaches require specialized expertise; few published cases exist and no center standards are enumerated in these chunks.