Hematopoietic Cell Transplantation for Testicular Cancer
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Aetna's clinical policy bulletin defining medical necessity criteria for hematopoietic cell transplantation (primarily autologous) in persons with testicular cancer, and listing procedures considered experimental/investigational (including allogeneic transplants and autologous as initial therapy).
No material clinical or coverage changes.
Coverage Summary
Scope: Aetna's Clinical Policy Bulletin (Number 0617) defines medical necessity criteria for hematopoietic cell transplantation in persons with testicular cancer, focusing primarily on autologous approaches (including tandem/autologous consolidation) and specifying procedures considered experimental/investigational. Coverage stance: mixed (some autologous transplants covered when criteria met; other approaches not covered). Status/current: CURRENT.
Medical-Necessity Criteria
Medically Necessary
Aetna considers the following types of hematopoietic cell transplantations medically necessary for testicular cancer when criteria are met:
Medically Necessary criteria
- Autologous HCT for refractory or partial responders: Autologous hematopoietic cell transplantation for the treatment of persons with testicular cancer who do not attain a complete remission after an initial course of standard-dose chemotherapy, i.e., those with refractory (less than 50% reduction in tumor burden) testicular cancer or those exhibiting a partial response (at least a 50% reduction in tumor burden).refractory: <50% reduction; partial response: >=50% reduction
- Autologous HCT as consolidation for relapse: Autologous hematopoietic cell transplantation as consolidation therapy for persons with testicular cancer who relapse after an initial course of standard-dose chemotherapy.
- Tandem autologous HCT for relapsed disease: Tandem autologous hematopoietic cell transplantation for persons with testicular cancer who have relapsed.
Experimental and Investigational (Not Covered)
The following are considered experimental and investigational because effectiveness has not been established:
Experimental and Investigational exclusions
- Autologous HCT as initial therapy (Not Covered): Autologous hematopoietic cell transplantation as initial treatment (i.e., instead of an initial course of standard-dose chemotherapy with Food and Drug Administration-approved drugs) of persons with testicular cancer.
Not covered - effectiveness not established.
- Allogeneic HCT (Not Covered): Allogeneic hematopoietic cell transplantation for the treatment of persons with testicular cancer.
Not covered - effectiveness not established.
Not Covered / Experimental Approaches
Non-coverage callout: Autologous hematopoietic cell transplantation used as initial treatment instead of standard‑dose chemotherapy is considered experimental/investigational and is not covered. Similarly, allogeneic hematopoietic cell transplantation for testicular cancer is considered experimental/investigational and is not covered because effectiveness has not been established.
Coding
| 38206-38230 | Bone marrow or stem cell services/procedures (except allogenic). |
| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation. |
| 96401-96549 | Chemotherapy administration. |
| S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition. |
| C62.00-C62.92 | Malignant neoplasm of testis. |
| D07.69 | Carcinoma in situ of other male genital organs [testis]. |
Provider Actions
Selection criteria required for coverage
Providers must ensure that autologous (including tandem) transplantation meets the specified medical necessity criteria to qualify for coverage: refractory disease defined as <50% tumor reduction; partial response defined as ≥50% reduction; or relapse after an initial course of standard-dose chemotherapy.
Requests for excluded procedures will be denied
Requests for the following procedures will be denied as experimental/investigational or not covered for the indications in this policy: autologous transplantation as initial therapy instead of standard‑dose chemotherapy, and allogeneic hematopoietic cell transplantation for testicular cancer.
Background & Evidence
Background: Testicular germ cell tumors (seminomas and non-seminomas) typically affect men aged ~20–40 and are staged I–III based on local and metastatic spread. First-line treatment for advanced disease is cisplatin‑based combination chemotherapy (commonly cisplatin, bleomycin, etoposide for 3–4 cycles), often followed by surgery for residual masses. Salvage regimens for relapsed disease include cisplatin plus ifosfamide with etoposide or vinblastine. For relapsed or refractory disease, high‑dose chemotherapy with autologous stem cell transplantation (ASCT/ABMT), including tandem ASCT approaches, has been used and multiple series and reviews report durable remissions (reported CR rates and durable remissions in select refractory patients and pooled data supporting use of ≥2 HDCT cycles with ASCT in relapsed/refractory germ cell cancer).
Revision History
Policy became effective.
Policy last reviewed and updated.
Scheduled next policy review date.
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