CurrentBlue Cross Blue Shield - MassachusettsPolicy 143

Hematopoietic Cell Transplantation (HCT) for Non-Hodgkin and other lymphomas

Defines medical necessity criteria, coverage positions (medically necessary vs investigational) and prior authorization requirements for autologous and allogeneic hematopoietic cell transplantation (HCT) across lymphoma subtypes for commercial members. Includes coding guidance and references; outpatient/inpatient prior authorization rules noted.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyHematopoietic Cell Transplantation (HCT) for Non-Hodgkin and other lymphomas

Policy CodePolicy 143

Change TypeAnnual review; clarifications; additions

Effective Date

Next Review Date2025-10

Key ActionPrecertification/prior authorization is required for inpatient procedures and providers must submit initial authorization requests using Authorization Manager with the servicing provider and facility NPIs entered appropriately.

POLICY UPDATE CHANGES

Clarified coding information.

Annual policy review updated description, summary, and references with policy statements unchanged.

Policy clarified to include authorization requests using Authorization Manager.

Medically necessary policy statement added for hepatosplenic T-cell lymphoma.

Medicare information removed referencing local and national coverage determinations.

Bone marrow harvesting codes were removed and outpatient prior authorization noted.

MultipleCovered Indications (conditional)

38240, S2142Key codes listed (informational)

Authorization requirement

Coverage Summary

This policy covers hematopoietic cell transplantation (HCT) for Non-Hodgkin and other lymphomas and defines disease‑specific medical necessity criteria for autologous and allogeneic HCT across multiple lymphoma subtypes. Effective/last review date: last review 2025-10. Coverage stance is mixed; key takeaways are that HCT may be medically necessary for selected indications (salvage therapy, consolidation in high‑risk DLBCL, consolidation or salvage in various chemosensitive relapses) across multiple lymphoma subtypes, while other uses (for example tandem transplants and some consolidation scenarios) are considered investigational. Preauthorization is required for inpatient procedures across all products, and outpatient prior authorization requirements vary by product (outpatient prior authorization required for certain commercial products).

HCT policy summary

Policy number143

StatusCURRENT

Last review2025-10

Covered Indications (conditional)Multiple lymphoma subtypes

Authorization requirementPreauthorization required (inpatient); outpatient prior auth varies by product — use Authorization Manager for requests

Key codes listed (informational)CPT: 38240, 38241; HCPCS: S2142, S2150

Medical Necessity Criteria (disease-specific)

General medical necessity criteria for HCT in NHL and related lymphomas

General medical necessity criteria for hematopoietic cell transplantation (HCT) in non-Hodgkin lymphoma (NHL) and related lymphomas.

Indications (ONE of)

Salvage therapy for individuals who do not achieve a complete remission (CR) after first-line treatment (induction) with a full course of standard-dose chemotherapy.
To consolidate a first CR in individuals with diffuse large B-cell lymphoma (DLBCL) with an adjusted International Prognostic Index score that predicts a high- or high-intermediate risk of relapse.
To achieve or consolidate a CR for those in a chemosensitive first or subsequent relapse.

Mantle Cell Lymphoma (MCL)

Mantle cell lymphoma (MCL) disease‑specific positions.

Coding

Covered CPT codes (informational list)CPTCovered

38240
38241	Hematopoietic progenitor cell (HPC); autologous transplantation

Covered HCPCS codes (informational list)HCPCSCovered

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)

Policy history notes a 10/2025 Clarified coding information entry. Coding lists in the policy are provided for informational purposes and inclusion/exclusion of a code does not by itself determine coverage. Preauthorization/coding implications: precertification/prior authorization is required for inpatient procedures for all products; outpatient prior authorization requirements vary by product and are required for certain commercial outpatient services. Providers must submit authorization requests via Authorization Manager and follow the specified provider/facility NPI entry guidance.

Provider Actions & Prior Authorization

Prior Authorization

Precertification/Prior Authorization required

Precertification/prior authorization is required for services described in this policy for inpatient procedures across all products; outpatient prior authorization requirements vary by product and the policy notes outpatient prior authorization is required for certain commercial products.

Inpatient: precertification/prior authorization required for all products
Outpatient: prior authorization requirements vary by product; required for certain commercial products

Documentation Required

Authorization Manager submission requirements

Providers must use Authorization Manager to submit initial authorization requests for services. Enter the appropriate surgeon's NPI or provider ID as the servicing provider (not the billing group) and enter the facility's NPI or provider ID for where services are being performed. For commercial members, requests must meet medical policy guidelines.

Background & Evidence

Hematopoietic cell transplantation (HCT) is the intravenous infusion of hematopoietic stem cells to restore bone marrow and immune function after marrow‑ablative cytotoxic therapy. HCT can be autologous (stem cells obtained from the transplant recipient) or allogeneic (stem cells from a donor), and allogeneic HCT requires assessment of immunologic compatibility by HLA typing to identify acceptable donors. Conditioning regimens vary in intensity from conventional myeloablative approaches (high‑dose cytotoxic therapy with or without total body irradiation) to reduced‑intensity conditioning (RIC), which uses lower doses of cytotoxic drugs or less intense radiotherapy to balance relapse risk and treatment‑related morbidity. Umbilical cord blood is an allogeneic stem cell source; cord blood cells are antigenically naive and are associated with a lower incidence of rejection or graft‑versus‑host disease, and cord blood may be medically necessary when no suitably matched donor is available and other criteria are met.

Definitions

Evidence summary

Medicare Determinations

Name	Number	Type	Effective
National Coverage Determination for Stem Cell Transplantation	Formerly 110.8.1 (110.23)	NCD	2016

Revision History

4/2020clarified

Bone marrow harvesting codes were removed and outpatient prior authorization is not required.

1/2023removed

Medicare information removed referencing local and national coverage determinations.

7/2023added

Medically necessary policy statement added for hepatosplenic T-cell lymphoma (effective 7/1/2023).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyHematopoietic Cell Transplantation (HCT) for Non-Hodgkin and other lymphomas

Policy CodePolicy 143

Change TypeAnnual review; clarifications; additions

Effective Date

Next Review Date2025-10

On This Page

MCL coverage positions

Autologous HCT to consolidate a first remission may be MEDICALLY NECESSARY.
Allogeneic HCT, myeloablative or reduced‑intensity conditioning, as salvage therapy may be MEDICALLY NECESSARY.
Allogeneic HCT is considered INVESTIGATIONAL to consolidate a first remission.
Autologous HCT is considered INVESTIGATIONAL as salvage therapy.

Indolent B-cell NHL subtypes

Indolent B‑cell non‑Hodgkin lymphoma (NHL) subtypes disease‑specific positions.

Indolent B‑cell NHL coverage positions

As salvage therapy for individuals who do not achieve CR after first‑line treatment (induction) with a full course of standard‑dose chemotherapy, autologous or allogeneic HCT may be MEDICALLY NECESSARY.
To achieve or consolidate CR for those in a first or subsequent chemosensitive relapse, whether or not their lymphoma has undergone transformation to a higher grade, autologous or allogeneic HCT may be MEDICALLY NECESSARY.
Either autologous HCT or allogeneic HCT is considered INVESTIGATIONAL to consolidate a first CR for individuals with indolent NHL B‑cell subtypes.

Diffuse large B-cell lymphoma (DLBCL) - consolidation

Diffuse large B‑cell lymphoma (DLBCL) — consolidation after initial therapy.

Specific consolidation indication

Disease is diffuse large B‑cell lymphoma (DLBCL).
Patient achieved a first complete remission (CR) after a full course of standard‑dose induction chemotherapy.
Adjusted International Prognostic Index score predicts a high‑ or high‑intermediate risk of relapse.

T-cell or NK-cell (peripheral T-cell) lymphoma

Mature T‑cell or NK‑cell (peripheral T‑cell) lymphoma disease‑specific positions.

T‑cell / NK‑cell lymphoma coverage positions

Autologous HCT may be MEDICALLY NECESSARY to consolidate a first complete remission in high‑risk peripheral T‑cell lymphoma.
Autologous or allogeneic HCT (myeloablative or reduced‑intensity conditioning) may be MEDICALLY NECESSARY as salvage therapy for mature T‑cell or NK‑cell (peripheral T‑cell) lymphoma.
Allogeneic HCT is considered INVESTIGATIONAL to consolidate a first remission.

Hepatosplenic T-cell lymphoma (HSTCL)

Hepatosplenic T‑cell lymphoma (HSTCL) disease‑specific positions.

HSTCL coverage positions

Allogeneic HCT may be considered MEDICALLY NECESSARY to consolidate a first complete remission or partial response.
Autologous HCT may be considered MEDICALLY NECESSARY to consolidate a first response if a suitable donor is not available or for individuals who are ineligible for allogeneic HCT.
Autologous or allogeneic HCT as initial therapy (i.e., without a full course of standard‑dose induction chemotherapy) is considered INVESTIGATIONAL.

Reduced-intensity conditioning (RIC) allogeneic HCT

Reduced‑intensity conditioning (RIC) allogeneic HCT positions.

RIC indication

Reduced‑intensity conditioning allogeneic HCT may be MEDICALLY NECESSARY in patients who meet criteria for an allogeneic HCT but who do not qualify for a myeloablative allogeneic HCT.

Tandem transplants

Tandem transplants positions.

Tandem transplant position

Tandem transplants are considered INVESTIGATIONAL to treat patients with any stage, grade, or subtype of NHL.

Stem cell source and cord blood

Stem cell source and cord blood positions and conditions.

Bone marrow or peripheral blood stem cells when harvested from the patient prior to marrow‑ablative therapy or from a donor after verification that donor and recipient are well matched with respect to human leukocyte antigens (HLA) may be considered MEDICALLY NECESSARY.
Umbilical cord stem cell support as an acceptable cell source
- There is no other available stem‑cell donor with the same or better matching characteristics.
- Recipient is a child or adult.
- Donors may be related or unrelated.
Collection and storage of cord blood from a neonate when an allogeneic transplant is imminent in an identified recipient with a diagnosis consistent with possible need for allogeneic transplant may be considered MEDICALLY NECESSARY.

Use Authorization Manager to submit initial authorization requests
Enter servicing provider NPI or provider ID (surgeon), not billing group
Enter facility NPI or provider ID for service location
Commercial requests must meet medical policy guidelines

9/2023clarifiedLatest

Policy clarified to include authorization requests using Authorization Manager prior authorization process.

3/2025revised

Annual policy review: description, summary, and references updated; policy statements unchanged.

10/2025clarified

Clarified coding information.