CurrentCapital BluecrossPolicy MP 9.056

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Defines medical necessity criteria for myeloablative and reduced-intensity conditioning allogeneic hematopoietic cell transplantation for individuals with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN), lists applicable diagnoses and risk stratification guidance, and provides coding guidance.

Policy Summary

PayerCapital Bluecross

PolicyAllogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Policy CodePolicy MP 9.056

Change TypeAdministrative and minor clarifications (no material clinical changes)

Effective DateApr 1, 2025

Next Review Date

Key ActionProviders must document WHO classification diagnosis and IPSS (or 5-category IPSS) risk stratification, including blast percentage, cytopenias, cytogenetics, transfusion dependence, and HCT-CI score to support medical necessity for allo-HCT.

SourceLink

POLICY UPDATE CHANGES

ICD-10 code C94.6 revised effective 10/01/2022.

Added ICD-10 codes C88.80, C88.81, C88.90, and C88.91 and removed C88.8 effective 10/01/2024.

Removed NCCN statement from policy.

Policy statement verbiage changed with same intent; no change to coding.

Multiple consensus and minor reviews with no changes to policy statements noted between 2020 and 2025.

2Covered Conditioning Types

>=40%Typical 3-5 year OS reported

RIC vs MACRIC vs MAC tradeoff

4ICD-10 code changes noted

Coverage Summary

This policy (MP 9.056) defines medical necessity criteria for myeloablative and reduced-intensity conditioning (MAC and RIC) allogeneic hematopoietic cell transplantation (allo-HCT) for individuals with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Payer: Capital Blue Cross. Effective date: 4/1/2025. Status: CURRENT. The policy requires WHO-classified diagnoses and IPSS (or updated 5-category IPSS) risk stratification to support transplant decisions and lists applicable ICD-10 and procedure coding guidance.

Headline thresholds: IPSS High Risk: total score ≥ 2.5 (Intermediate-2 and High); Blast percentage consideration for MPN: increasing blasts >5%; Age for RIC consideration: typically >60 years (MPN: age 60–65 years); example severe cytopenias such as neutrophils <500/mm3 or platelets <20,000/mm3; and HCT-CI >2 as a comorbidity threshold favoring RIC. Coverage stance: mixed (medically necessary when Policy Guidelines met; investigational when criteria are not met).

Policy summary

Policy numberMP 9.056

PayerCapital Bluecross

Effective date2025-04-01

StatusCURRENT

SubjectAllogeneic hematopoietic cell transplantation (allo-HCT) for MDS and MPN

Scope summaryDefines medical necessity criteria for myeloablative and reduced-intensity conditioning allo-HCT for MDS and MPN, lists applicable diagnoses and risk-stratification guidance, and provides coding guidance.

Medically Necessary and Risk-Adapted Criteria

Medically Necessary Indications

Myeloablative allo-HCT or reduced-intensity conditioning (RIC) allo-HCT may be considered medically necessary when ALL of the following apply:

ALL of the following

Diagnosis of a myelodysplastic syndrome (MDS) or myeloproliferative neoplasm (MPN) as defined by WHO classification and Policy Guidelines
See Policy Guidelines section for specific WHO categories and subtypes (MDS, MPN, MDS/MPN, etc.)
Individual meets risk-stratification criteria supporting transplant (e.g., IPSS intermediate-2 or high risk for MDS; progression to myelofibrosis toward acute leukemia, cytopenias, transfusion dependence, increasing blast % over 5%, age considerations for MPN)IPSS total score ≥2.5 groups Intermediate-2 and High as high-risk
IPSS and updated 5-category IPSS discussed in Policy Guidelines; specific thresholds described in tables PG1/PG2
ONE of

Investigational / Not Medically Necessary

Allo-HCT that does not meet the Policy Guidelines criteria is considered:

Investigational/unproven due to insufficient evidence when criteria in Policy Guidelines are not met

Myeloablative allo-HCT or RIC allo-HCT for MDS and MPN that does not meet policy guideline criteria is considered investigational

Coding

Covered Procedure Codes (when medically necessary)CPTCovered

38214	Allogeneic transplant procedure code listed in policy as covered when medically necessary
38205	Related hematopoietic cell transplantation procedure code (listed with equivalence to 38215 in policy text)
38215	Related hematopoietic cell transplantation procedure code
38207	Related hematopoietic cell transplantation procedure code (listed with equivalence to 38230)
38230	Related transplantation procedure code
38208	Related hematopoietic cell transplantation procedure code (listed with equivalence to 38240)
38240	Related transplantation procedure code
38209	Related hematopoietic cell transplantation procedure code (listed with equivalence to 38242)
38242	Related transplantation procedure code
38210	Related hematopoietic cell transplantation procedure code (listed with equivalence to S2150)

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Relevant ICD-10 Diagnosis Codes (listed as covered when medically necessary)ICD-10Covered

C88.80	Other malignant immunoproliferative diseases not having achieved remission
C88.81	Other malignant immunoproliferative diseases, in remission
C88.90	Malignant immunoproliferative disease, unspecified not having achieved remission
C88.91	Malignant immunoproliferative disease, unspecified, in remission
C92.10	Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.11	Chronic myeloid leukemia, BCR/ABL-positive, in remission
C92.12	Chronic myeloid leukemia, BCR/ABL-positive, in relapse
C92.20	Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission
C92.21	Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission
C92.22	Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse

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Policy numbermixed

MP 9.056

Policy identifier

ICD-10 coding updates (administrative)ICD-10

C94.6	Revised (effective 10/01/2022)
C88.80	Added (effective 10/01/2024)
C88.81	Added (effective 10/01/2024)
C88.90	Added (effective 10/01/2024)
C88.91	Added (effective 10/01/2024)
C88.8	Removed (effective 10/01/2024)

Provider Actions & Billing Guidance

Prior Authorization

Prior authorization likely required

Providers should verify member benefits and seek prior authorization when applicable to confirm coverage for allogeneic HCT, as coverage is determined by the member's benefit plan and medical policy.

Documentation Required

Document diagnosis and risk stratification

Document the diagnosis using WHO classification and record risk stratification to support medical necessity for allo‑HCT.

WHO classification (specific WHO category/subtype)
IPSS or updated 5‑category IPSS
Blast percentage (marrow blasts %)
Cytopenias (number/severity of cytopenias)

Background, Evidence, and Definitions

Allogeneic HCT is the only potentially curative option for MDS and MPN but is selected based on patient and disease factors. Myeloablative conditioning (MAC) is used for medically fit individuals who can tolerate conventional myeloablative regimens; reduced-intensity conditioning (RIC) regimens were developed to extend transplant candidacy to older or comorbid individuals by lowering toxicity while allowing engraftment and leveraging graft-versus-malignancy effects.

Use of allo-HCT and choice of conditioning intensity are guided by age, performance status, comorbidities (e.g., HCT-CI), disease risk (IPSS or updated 5-category IPSS), cytogenetic risk, blast percentage and trends, transfusion dependence, and donor availability/type (HLA-identical sibling, related with single-locus mismatch, matched unrelated donor, or haploidentical donor with higher GVHD/morbidity risk).

Evidence	Summary
Reported 3-5 year overall survival
40% to 50% (observational studies) as typical reported estimates for 3- to 5-year overall survival
RIC vs MAC outcomes
RIC: lower non-relapse mortality; higher relapse; similar overall survival in selected high-risk/older or comorbid individuals (risk‑adapted use)
Key guideline references
NCCN MDS v1.2025; NCCN MPN v2.2024; ASTCT/ASBMT indications guidance; CMS NCD for Stem Cell Transplantation 2024

Glossary: Allo-HCT: allogeneic hematopoietic cell transplantation using donor-derived hematopoietic stem cells; MAC: myeloablative conditioning regimen prior to allo-HCT intended to ablate recipient marrow; RIC: reduced-intensity conditioning regimen designed to reduce toxicity while allowing engraftment; IPSS: International Prognostic Scoring System for Myelodysplastic Syndromes, a risk-stratification tool based on blasts, cytopenias, and cytogenetics; HCT-CI: Hematopoietic Cell Transplantation Comorbidity Index, used to assess transplant-related comorbidity burden.

Medicare Determinations

Year	Name/Number	Type
2024
National Coverage Determination for Stem Cell Transplantation (formerly 110.8.1 / 110.23)
NCD

Revision History

02/06/2020clarified

Consensus Review: Verbiage added to match BCBSA policy in the policy statement; Policy guidelines, background, and references updated; coding reviewed and corrected.

01/04/2021clarified

Consensus Review: No changes to the policy statements; background, rationale, references, and coding reviewed.

02/24/2021clarified

Consensus Review: No change to policy statements; references and coding reviewed.

Policy Summary

PayerCapital Bluecross

PolicyAllogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Policy CodePolicy MP 9.056

Change TypeAdministrative and minor clarifications (no material clinical changes)

Effective DateApr 1, 2025

Next Review Date

SourceLink

On This Page

MAC: Myeloablative conditioning (MAC) allo-HCT for individuals who can tolerate a conventional myeloablative regimen (medically fit)

RIC: Reduced-intensity conditioning (RIC) allo-HCT for individuals at high risk of intolerance to MAC (e.g., age typically >60 years; multiple comorbidities; HCT-CI >2; low Karnofsky Performance Status; organ dysfunction; prior intensive chemotherapy)Age >60 years; HCT-CI >2

RIC is a risk-adapted strategy when MAC intolerance is likely

Appropriate donor available or donor strategy considered (HLA-identical sibling 6/6, related donor with single-locus mismatch, matched unrelated donor, haploidentical donor considered with higher GVHD risk)

Donor type influences risk; haploidentical donors may have higher GVHD/morbidity

Operational notes: Providers must document WHO classification diagnosis and IPSS (or 5-category IPSS) risk stratification, including blast percentage, cytopenias, cytogenetics, transfusion dependence, and HCT-CI score to support medical necessity for allo-HCT.

Include reasons for selecting MAC versus RIC (age, comorbidities, performance status, organ dysfunction). Prior authorization or benefit verification likely required.

Risk-adapted use of RIC

Evidence-supported situations where RIC may be considered:

ANY of the following

MDS: older age; IPSS intermediate-2 or high risk; multiple comorbidities; red blood cell transfusion dependence; neutropenia; thrombocytopenia; high-risk cytogenetics; increasing blast percentageIPSS total score ≥2.5; HCT-CI >2; examples of severe cytopenias: neutrophils <500/mm3; platelets <20,000/mm3; blast percentage increasing (see Policy Guidelines)
MPN: cytopenias; transfusion dependence; increasing blast percentage over 5%; age 60 to 65 yearsBlast % >5%; age 60-65 years

Threshold guidance: RIC is a risk-adapted strategy for individuals whose age (typically >60 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy, low Karnofsky Performance Status) preclude standard MAC; HCT-CI score higher than 2 suggests consideration for RIC.Age typically >60 years; HCT-CI >2; blast % >5% for MPN consideration

Cytogenetics (karyotype risk group)

Transfusion dependence (red blood cell transfusion dependence)

HCT‑CI score (hematopoietic cell transplantation comorbidity index)

Documentation Required

Justify conditioning intensity

Document clinical justification for selecting myeloablative conditioning (MAC) versus reduced‑intensity conditioning (RIC), aligned with the policy's risk‑adapted strategy.

Age (e.g., typically >60 years favors RIC)
Comorbidities (e.g., HCT‑CI >2)
Performance status (e.g., low Karnofsky Performance Status)
Organ dysfunction (e.g., liver or kidney dysfunction)

Billing Rule

Use listed procedure codes

Report allogeneic HCT procedures using the CPT/HCPCS procedure codes listed in the coding section when medically necessary and consistent with the member's benefit plan.

38214
38205
38215
38207
38230
38208
38240
38209
38242
38210
S2150
38211
38212
38213
Instruction: Report these codes when medically necessary and consistent with the member's benefit plan.

Billing Rule

Use updated ICD-10 codes effective 10/01/2024

Use the updated ICD‑10 diagnosis codes and reflect administrative code changes in claims per the coding updates effective dates.

C94.6 (revised effective 10/01/2022)
C88.80 (added effective 10/01/2024)
C88.81 (added effective 10/01/2024)
C88.90 (added effective 10/01/2024)
C88.91 (added effective 10/01/2024)
C88.8 (removed effective 10/01/2024)
Note: Claims should reflect these additions/removals per the administrative coding updates.

Documentation Required

Align documentation with referenced guidelines and policy

Align clinical documentation and supporting evidence with the guideline and policy references that inform coverage determinations.

NCCN (NCCN MDS v1.2025; NCCN MPN v2.2024)
ASTCT/ASBMT guidance (Indications for Hematopoietic Cell Transplantation and Immune Effector Cell Therapy)
CMS National Coverage Determination (NCD) for Stem Cell Transplantation (2024)

02/16/2022clarified

Consensus Review: Policy statement unchanged; Policy Guidelines revised and NCCN language added; background and rationale updated; references added.

08/16/2022revised

Administrative coding update recorded 08/16/2022: ICD-10 code C94.6 revised effective 10/01/2022.

02/17/2023clarified

Minor Review: No changes to policy statement; Policy Guidelines section heavily revised; background and references updated.

02/08/2024clarified

Minor Review: Policy statement verbiage changed with same intent; references updated; coding reviewed; no change to coding.

08/16/2024added

Administrative Update recorded 08/16/2024: Added ICD-10 codes C88.80, C88.81, C88.90, and C88.91 and removed C88.8 effective 10/01/2024.

11/19/2024removed

Administrative note dated 11/19/2024: Removed NCCN statement from policy.

01/13/2025clarifiedLatest

Consensus Review: No changes to the policy statements; background, rationale, references, and coding reviewed.