CurrentBlue Cross Blue Shield - MassachusettsPolicy 212

Allogeneic and Autologous Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

Policy governs medical necessity and prior authorization requirements for allogeneic and autologous hematopoietic cell transplantation (HCT) as treatments for chronic myeloid leukemia (CML) for commercial members of Blue Cross Blue Shield Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyAllogeneic and Autologous Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

Policy CodePolicy 212

Change TypeClarification and annual review

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests via Authorization Manager including facility and servicing provider NPIs for inpatient procedures (preauthorization required).

SourceLink

POLICY UPDATE CHANGES

Policy clarified to include prior authorization requests using Authorization Manager.

Annual policy review with literature update through November 14, 2025; policy statements unchanged.

Policy updated with literature review through November 14, 2025; no references added. Policy statements unchanged.

Medicare information removed; see separate Medicare management policy.

Outpatient prior authorization requirement changed over time; outpatient prior authorization is not required (action in 4/2020) and earlier (1/2019) outpatient prior authorization was required for all commercial products.

38240CPT listed

S2142, S2150HCPCS listed

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Coverage Criteria for Hematopoietic Cell Transplantation in CML

Coverage stance for HCT in CML

Covered when ALL of the following are met:

Allogeneic myeloablative: Allogeneic HCT using a myeloablative conditioning regimen may be considered MEDICALLY NECESSARY as a treatment of chronic myeloid leukemia.

Allogeneic reduced-intensity: Allogeneic HCT using a reduced-intensity conditioning regimen may be considered MEDICALLY NECESSARY for individuals who meet clinical criteria for an allogeneic HCT but are not candidates for myeloablative conditioning (eg, age typically >60 years or comorbidities).

Autologous HCT is INVESTIGATIONAL as a treatment of chronic myeloid leukemia.

Autologous hematopoietic cell transplantation (HCT) is investigational as a treatment for chronic myeloid leukemia (CML) and is therefore not covered as standard therapy.

Medicare-specific information has been removed from this policy. For Medicare Advantage/local and national coverage determinations, refer to MP #132.

No additional conditions are specified as not medically necessary in this policy beyond the statement that autologous HCT for CML is investigational.

Coding and Billing Codes

CPT CodesCPTCovered

38240

Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor

HCPCS CodesHCPCSCovered

S2142	Cord blood derived stem-cell transplantation, allogeneic.
S2150	Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)

Coding notes/historymixed

No codes listed

Age consideration for conditioning — inv-08

Typical age threshold>60 years

ContextAge >60 years cited as a common reason to favor reduced-intensity conditioning when myeloablative conditioning is not tolerated

Other factors besides ageComorbidities (eg, liver or kidney dysfunction, generalized debilitation), prior intensive chemotherapy, low Karnofsky Performance Status

ICD-10 coding update effective date — inv-09

ICD-10 coding update effective date10/2015

Policy history note

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required for inpatient services described in this policy for all products. Outpatient prior authorization is required for commercial product types (Commercial Managed Care [HMO and POS], Commercial PPO, and Indemnity).

Inpatient: Precertification/preauthorization IS REQUIRED for all products when the procedure is performed inpatient.
Outpatient: Commercial Managed Care (HMO and POS), Outpatient = Prior authorization is required.
Outpatient: Commercial PPO and Indemnity, Outpatient = Prior authorization is required.

Note

Authorization Manager Submission Details

Providers must submit initial authorization requests using Authorization Manager. It is available 24/7 and is the preferred method to review authorization requirements, request authorizations, submit clinical documentation, check case status, and view/print decision letters. For commercial members, requests must meet medical policy guidelines.

Enter the facility's NPI or provider ID for where services will be performed.

Background on Chronic Myeloid Leukemia and HCT

Chronic myeloid leukemia (CML) is a hematopoietic stem cell disorder driven by the Philadelphia chromosome (BCR-ABL), which produces a constitutively active tyrosine kinase that dysregulates hematopoietic proliferation. Most patients present in the chronic phase, but the disease can progress to accelerated phase and blast crisis. Tyrosine kinase inhibitors (TKIs) are first-line therapy and have substantially altered transplant practice; however, allogeneic HCT remains the only potentially curative option for patients with TKI resistance, intolerance, or advanced-phase disease.

Definitions and Guideline References

Reduced-intensity conditioning (RIC) definition — inv-19

DefinitionPretransplant regimens using lower doses of cytotoxic drugs or less intense radiotherapy intended to be nonmyeloablative to reduce treatment-related morbidity and mortality while allowing graft-versus-malignancy effects.

PurposeReduce immediate toxicity in patients not eligible for myeloablative conditioning while permitting engraftment and graft-versus-malignancy effect.

Typical candidatesIndividuals not candidates for myeloablative conditioning due to age or comorbidities (eg, age typically >60 years).

Allogeneic HCT definition — inv-20

DefinitionInfusion of donor hematopoietic stem cells (allogeneic HCT).

Key consideration

Transplant Candidate Criteria

Transplant candidate criteria

Candidates for transplant include patients with CML who:

TKI failure or intolerance: Have disease progression on TKI therapy, resistance (including presence of T315I) or intolerance to TKIs such that allogeneic HCT is indicated.

Advanced phase disease: Are in accelerated phase or blast crisis where allogeneic HCT is the curative option.

Not candidate for myeloablative conditioning: Meet clinical criteria for allogeneic HCT but are not candidates for myeloablative conditioning due to age (typically >60 years) or comorbidities; may be considered for reduced-intensity conditioning allogeneic HCT.

Contraindications

Documented contraindications are acknowledged in the policy context, but specific contraindications are not listed in this section. Providers should document any patient-specific contraindications in the medical record and follow center-specific and transplant-society guidance when assessing transplant eligibility.

Evaluation and Pre-transplant Testing Requirements

Documentation Required

Evaluation requirements — HLA testing and transplant evaluation

Standard pretransplant evaluation should include HLA compatibility testing and the routine transplant evaluation steps described in the policy; HLA typing is important to reduce rejection and GVHD risk.

Perform standard HLA compatibility testing as part of transplant evaluation.
Complete clinical evaluation to determine transplant candidacy (including assessment of TKI response, disease phase, and comorbidities).

Transplant Center and Administrative Requirements

Documentation Required

Center requirements — precertification and Authorization Manager submissions

Transplant centers must obtain precertification/preauthorization and submit authorization requests through Authorization Manager per policy instructions to ensure accurate processing and adjudication.

Precertification/preauthorization required for inpatient procedures.
Use Authorization Manager for initial authorization requests and include required facility and servicing provider identifiers.

Post-Transplant Coverage and Global Billing

Post-transplant care included in S2150 global definition — inv-26

S2150 global definitionIncludes bone marrow or blood-derived peripheral stem-cell harvesting and transplantation (allogeneic or autologous) and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical, surgical, diagnostic and emergency services).

Post-transplant services includedImmunosuppressive management and routine post-transplant monitoring and care are included within the S2150 global days.

Implication for billingPost-transplant care days billed under S2150 encompass associated drugs, hospital services, and related medical care during the global period.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyAllogeneic and Autologous Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

Policy CodePolicy 212

Change TypeClarification and annual review

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests via Authorization Manager including facility and servicing provider NPIs for inpatient procedures (preauthorization required).

SourceLink

On This Page

Documentation Required

Documentation and Prior Authorization Routing

Policy history documents administrative changes to prior authorization handling over time. Notably, outpatient prior authorization requirements have changed historically (see policy history). Providers should follow the current Authorization Manager instructions and the guidance in this policy when submitting requests.

9/2023: Policy clarified to include prior authorization requests using Authorization Manager.
4/2020: Bone marrow harvesting codes were removed; outpatient prior authorization was noted as not required at that time.
1/2019: Outpatient prior authorization was required for all commercial products including Medicare Advantage, effective 1/1/2019.
Annual reviews note updates to descriptions, summaries, and references without changing policy statements in multiple years.