Legacy language that previously asserted broad lack of evidence for tandem transplants outside the listed indications has been removed from the policy. The prior statement (criteria IV) that “current evidence does not support tandem transplants for any other indication than what is listed above” was deleted during revisions beginning 02/23 and retained in subsequent annual reviews, reflecting a policy-level change to rely on the updated indication and contraindication criteria rather than a blanket non‑coverage statement.

A former blanket non‑support statement for tandem transplants was explicitly removed (criteria IV removed). The policy now omits that blanket exclusion and instead defines coverage based on the specified indications and the updated contraindication list.

Tandem transplants for indications other than the specifically listed diagnoses (multiple myeloma, refractory germ cell tumors, and high‑risk neuroblastoma) were previously described as unsupported by the evidence; that language has been removed. The policy continues to identify those three diagnoses as the primary covered indications, and providers should follow the updated disease‑specific criteria when considering tandem approaches for other diagnoses on a case‑by‑case basis.

The prior blanket exclusion for tandem transplants was deleted and replaced by the revised coverage logic tied to the updated indications and the consolidated contraindication list. Current exclusions are determined by whether a member meets the specified indication criteria and lacks any of the contraindications enumerated in the revised I.B.1–I.B.6.

Contraindications: Requests for tandem autologous or tandem autologous→allogeneic transplant will be denied when the member has significant dysfunction of a major organ system or severe comorbidities. Specific contraindications listed in the policy include: bilirubin > 2 mg/dL; INR > 1.6 (unless the member is on oral anticoagulants); cardiac dysfunction with MUGA/echocardiogram EF < 45%; pulmonary impairment defined as FEV1 ≤ 50% predicted or DLCO ≤ 60% predicted; poor performance status (Karnofsky/Lansky < 70% or ECOG > 2); and uncontrolled or disseminated infection. (These items are enumerated in I.B.1–6 and I.B.6 in the policy.)

HIV-specific criteria: HIV-positive candidates must meet the policy-specified HIV criteria (I.B.10) to be considered. These requirements are: CD4 cell count > 200 cells/mm3, absence of active AIDS-defining opportunistic infection, and the member must be currently on effective antiretroviral therapy (ART). Requests lacking documentation that these HIV criteria are met may be denied.

Documentation to support criteria: Prior authorization requests must include clinical records that demonstrate eligibility against the listed indications and contraindications. Required documentation includes confirmed diagnosis and staging (for example, INRGSS/COG classification for neuroblastoma or documentation of relapsed testicular/ovarian germ cell tumor), objective organ function testing (bilirubin, INR/coagulation studies, MUGA/echocardiogram with EF, pulmonary function tests with FEV1 and DLCO), performance status scores, infection workup, and prior therapy response (e.g., degree of response in multiple myeloma such as VGPR). Providers should also submit relevant procedure and supply codes when applicable (e.g., CPT codes 38205, 38206, 38230, 38232, 38240, 38241 and HCPCS S2150) to support claims processing.

Post-transplant therapy considerations: The policy references evidence and NCCN guidance noting that maintenance therapy after SCT (for example, lenalidomide in multiple myeloma) is commonly considered and can affect sequencing decisions (single versus tandem) based on response to the first transplant. Clinicians should document planned or recommended post-transplant maintenance where relevant, and authorization requests should reflect whether maintenance therapy is part of the overall treatment plan.

Provider actions summary: For a complete and approvable prior authorization request, providers must (1) confirm the member meets the diagnosis-specific eligibility and updated policy sections (e.g., I.A.2 inclusion of ovarian germ cell tumors; I.A.3 neuroblastoma criteria aligned to INRGSS/COG), (2) show absence of any contraindications (I.B.1–6) or that HIV-specific criteria (I.B.10.a–c) are met, (3) supply documented objective testing results and performance status, and (4) include relevant procedure/supply CPT and HCPCS codes and any planned post-transplant therapy considerations to support clinical necessity and care coordination.

A tandem transplant is defined as a planned second course of high‑dose therapy and hematopoietic cell transplant performed within six months of the first transplant, typically using hematopoietic progenitor cells collected during the initial mobilization/harvest. The intent of tandem transplant is to intensify therapy to reduce residual tumor burden and lower relapse risk in selected high‑risk or refractory malignancies.

Material changes since the prior policy cycle include: addition of ovarian germ cell tumors to the covered indications (I.A.2); alignment of neuroblastoma staging and eligibility to the INRGSS/COG high‑risk definitions with updated age specifications expressed in months (I.A.3 updates); consolidation and simplification of contraindications by replacing the prior I.B.1–I.B.15 list with a new I.B.1–I.B.6 set; and addition of explicit HIV‑specific requirements (I.B.10.a–c: CD4 > 200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and current effective antiretroviral therapy). These operational changes were implemented across multiple annual reviews (notably 02/23, 02/24, 01/25, 01/26).