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CurrentCapital BluecrossPolicy MP 9.056

Allogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasms

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Defines medical necessity criteria and policy stance for myeloablative and reduced-intensity conditioning allogeneic hematopoietic cell transplantation (allo-HCT) in individuals with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). Applies to Capital BlueCross members in North Carolina.

Policy Summary

PayerCapital Bluecross

PolicyAllogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasms

Policy CodePolicy MP 9.056

Change TypeAdministrative — no material clinical changes

Effective DateJun 1, 2026

Last ReviewFeb 6, 2026

Next Review Date

Key ActionObtain prior authorization to confirm that medical necessity criteria are met for myeloablative or reduced-intensity allo-HCT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MP 9.056policy number

NCApplicable state

2conditioning intensities

>=60RIC age threshold

HLA 6/6ideal donor match

Coverage Criteria for Allogeneic Hematopoietic Cell Transplantation

Medical necessity criteria for allo-HCT

Covered when ALL of the following are met

Overall: Allo-HCT (myeloablative) may be considered medically necessary for individuals with myelodysplastic syndromes or myeloproliferative neoplasms per Policy Guidelines; RIC allo-HCT may be considered medically necessary for individuals who meet policy guidelines and are at high-risk for not tolerating a conventional myeloablative conditioning regimen.

See Policy Guidelines for disease-specific indications and risk stratification.

Indications-MDS: MDS individuals with increasing blasts, chromosomal abnormalities, significant cytopenias (e.g., neutrophils <500/mm3, platelets <20,000/mm3), or progression signaling transformation to AML are candidates for allo-HCT.

IPSS used for stratification; elevated LDH, marrow fibrosis, or β2-microglobulin may worsen prognostic category by one.

Indications-MPN: MPN individuals with progression to myelofibrosis or toward acute leukemia, or essential thrombocythemia with thrombotic/hemorrhagic complications, may be considered for allo-HCT. Consider cytopenias, transfusion dependence, increasing blasts >5%, and age.

Policy Summary

PayerCapital Bluecross

PolicyAllogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasms

Policy CodePolicy MP 9.056

Change TypeAdministrative — no material clinical changes

Effective DateJun 1, 2026

Last ReviewFeb 6, 2026

Next Review Date

Key ActionObtain prior authorization to confirm that medical necessity criteria are met for myeloablative or reduced-intensity allo-HCT.

SourceLink

On This Page

blast percentage >5%

Donor considerations: Preferred donors are HLA-identical siblings matched at HLA-A, -B, and -DR (6/6); related donors mismatched at one locus and matched unrelated donors are acceptable; haploidentical donors are possible but carry higher GVHD/morbidity risk.

RIC candidacy: Individuals typically >60 years or with comorbidities (liver/kidney dysfunction, prior intensive chemotherapy, low Karnofsky) may be candidates for RIC instead of MAC.age >60 years; presence of significant comorbidities

Coverage criteria for allo‑HCT

Covered when ALL of the following disease- and patient-related criteria are considered and documented as appropriate for allo‑HCT candidate selection:

Primary disease indications

MDS risk features: IPSS intermediate-2 or high risk, high‑risk cytogenetics, increasing blast percentage, transfusion dependence, significant cytopenias (neutrophils <500/mm3, platelets <20,000/mm3)
MPN risk features: Progression to myelofibrosis or toward acute leukemia; cytopenias; transfusion dependence; increasing blast percentage over 5%; age 60–65 yearsblast percentage >5%

Patient candidacy and conditioning: Patient is a candidate for either MAC or RIC based on age, comorbidities, performance status (e.g., Karnofsky), and HCT‑CI score; RIC consideration for age typically >60 or HCT‑CI >2 or other comorbidities.

Donor suitability: An acceptable donor is identified: ideally HLA‑identical sibling matched at HLA‑A, -B, -DR (6/6); related donors mismatched at one locus or matched unrelated donors via registry are considered; haploidentical donors may be used with consideration of increased GVHD and morbidity.

Coverage criteria — Allo-HCT for MDS and MPN

Covered when medically necessary for individuals with MDS or myeloproliferative neoplasms who meet transplant criteria

General coverage rationale: HCT is the only potentially curative treatment option for MDS and many myeloproliferative neoplasms; evidence (systematic reviews, RCTs, observational series) demonstrates improvement in net health outcome.

Supported by summary of evidence.

Conditioning selection: Either myeloablative conditioning (MAC) or reduced-intensity conditioning (RIC) may be used; RIC can be employed as a risk-adapted strategy in older or more comorbid individuals to reduce non-relapse mortality though it may increase relapse risk.

Selection tailored to fitness, age, comorbidities, and disease risk.

Allogeneic hematopoietic cell transplantation (allo‑HCT) — whether performed with conventional myeloablative conditioning (MAC) or reduced‑intensity conditioning (RIC) — that does not meet the Policy Guidelines criteria is considered investigational. The policy states there is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with allo‑HCT performed outside the specified guideline criteria.

Allo‑HCT is generally not offered to individuals who cannot tolerate either myeloablative conditioning (MAC) or reduced‑intensity conditioning (RIC) because of advanced age or significant comorbidities, unless an appropriately tailored RIC regimen is considered suitable. The policy describes RIC as an option for individuals unlikely to tolerate conventional MAC and discusses non‑myeloablative approaches intended to reduce treatment‑related morbidity.

Intense myeloablative conditioning regimens are limited to individuals who are sufficiently medically fit to tolerate substantial adverse effects (for example, risks of severe infections and organ toxicity). Conditioning intensity should be selected and tailored to the disease characteristics and the individual’s fitness, comorbidities, and performance status.

Within the provided excerpts there are no additional explicit exclusion conditions listed beyond those embedded in the policy guidelines and clinical selection criteria; policy history and administrative updates are recorded but do not add discrete exclusion statements in these chunks.

Allo‑HCT is not indicated when goals of care are limited to symptom control or when disease severity, poor performance status, comorbidities, or patient preference make transplant inappropriate. The policy emphasizes that transplantation is governed by age, performance status, comorbidities, risk category, and the individual’s treatment goals.

In the document excerpts provided there are no explicit statements labeled as 'not medically necessary' beyond the clinical guidance that transplant suitability depends on patient goals, fitness, and comorbid conditions.

Conditioning Regimens and Intensity

Regimen	Description	Coverage status
Conventional myeloablative conditioning (e.g., cyclophosphamide, busulfan with or without total body irradiation)
Administration of cytotoxic agents (such as cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to cause recipient bone marrow ablation; intended for medically fit individuals and associated with higher toxicity (opportunistic infections, organ damage)
Covered when medically necessary and policy criteria are met

Regimen	Description / selection considerations	Coverage status
Myeloablative conditioning (MAC)
High-dose cytotoxic agents with or without total body irradiation intended to ablate marrow; selection requires sufficient medical fitness given substantial adverse effects; choice based on patient fitness, age, comorbidities, and disease-specific factors
Covered when medically necessary and policy criteria are met

Regimen	Examples / evidence notes	Coverage status
Reduced-intensity conditioning (RIC)
Lower-dose cytotoxic drug regimens or less intense radiotherapy (e.g., fludarabine-based combinations such as fludarabine plus busulfan); intensity tailored to disease and individual condition to balance relapse risk and non-relapse mortality; multiple studies report durable remissions and long-term disease-free survival with RIC in high-risk MDS/AML
Covered when medically necessary and policy criteria are met (used for individuals who cannot tolerate MAC)

Procedure and Diagnosis Codes

Covered CPT/Procedure CodesCPTCovered

38205	Procedure code (listed)
38207	Procedure code (listed)
38208	Procedure code (listed)
38209	Procedure code (listed)
38210	Procedure code (listed)
38211	Procedure code (listed)
38212	Procedure code (listed)
38213	Procedure code (listed)
38214	Procedure code (listed)
38215	Procedure code (listed)

1–10 of 14

1/2

Covered ICD-10 Diagnosis CodesICD-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

1–10 of 29

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ICD-10 codes mentioned in policy historyICD-10

C94.6	ICD-10 code revised (referenced in policy history)
C88.80	ICD-10 code added
C88.81	ICD-10 code added
C88.90	ICD-10 code added
C88.91	ICD-10 code added
C88.8	ICD-10 code removed

inv-14: Marrow blasts, %

<5%IPSS marrow blasts score = 0

5-10%IPSS marrow blasts score = 0.5

11-20%IPSS marrow blasts score = 1.5

21-30%IPSS marrow blasts score = 2.0

inv-15: Karyotype score

GoodKaryotype score = 0

IntermediateKaryotype score = 0.5

PoorKaryotype score = 1.0

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior authorization required for allo‑HCT

Prior authorization is required to confirm that medical necessity criteria are met for myeloablative or reduced-intensity allo‑HCT as described in the policy guidelines; procedures that do not meet Policy Guidelines are considered investigational and may be denied.

Prior authorization is intended to verify that the individual meets the Policy Guidelines for allo‑HCT (MAC or RIC).
Allo‑HCT that does not meet the Policy Guidelines is considered investigational and may be denied.

Prior Authorization

Product- and program-specific prior authorization

Prior authorization requirements can vary by product and program; for Federal Employee Program (FEP) PPO members, refer to the FEP Medical Policy manual for applicable authorization procedures.

Policy applicability is subject to benefit variations across Capital BlueCross programs and products.
FEP PPO: follow the FEP Medical Policy manual referenced in the policy.

Prior Authorization

Prior authorization may be required for listed codes

Certain procedure and diagnosis codes listed as 'Covered when medically necessary' may require prior authorization depending on the member's product and benefit.

Examples of procedure codes listed: 38205–38215, 38230, 38240, 38242, S2150 (see coding section).
Extensive ICD‑10 diagnosis codes are listed in the coding section; identification of a code does not guarantee coverage and prior authorization may still apply.

Prior Authorization

Prior authorization operational details not specified

The provided excerpts do not specify detailed operational prior authorization processes (e.g., submission forms, timelines); providers should follow standard prior authorization channels for Capital BlueCross and verify requirements for the member's benefit.

Policy notes that prior authorization requirements are not specified in the provided document excerpts.
Contact Provider Services or Member Services for case-specific authorization instructions.

Note

Provider actions (not otherwise specified)

No specific provider actions are enumerated in the provided excerpts beyond documentation and authorization steps; follow policy guidance for criteria, documentation, and coding when submitting requests.

Providers should ensure medical necessity criteria and required documentation (see other callouts) are included with any authorization request.
If uncertain, contact Capital BlueCross Provider Services for required actions tied to member benefits.

Documentation Required

Document non‑transplant therapies when relevant

The policy references non-transplant management options (supportive care, hypomethylating agents, growth factors, ruxolitinib/fedratinib) as part of the treatment landscape prior to or instead of transplant for some individuals.

Supportive care: RBC/platelet transfusions, antibiotics, hematopoietic growth factors (erythropoietin, darbepoetin, G‑CSF).
Disease-directed therapies: FDA‑approved hypomethylating agents; ruxolitinib (for myelofibrosis) and other agents may be used before considering transplant.

Note

Justify conditioning approach (RIC vs MAC)

Conditioning intensity should be risk‑adapted: RIC is appropriate for individuals who are older or have comorbidities that preclude MAC; choice must be justified based on age, comorbidities, performance status, and HCT‑CI.

RIC defined as lower‑dose or less intense regimens to reduce non‑relapse mortality while maintaining graft‑versus‑malignancy effect.
Patients typically >60 years or with significant comorbidities may be candidates for RIC instead of MAC.

Documentation Required

Document IPSS risk stratification and supporting data

Document risk stratification for MDS using the IPSS, including marrow blast percentage, karyotype, and cytopenias, and include supporting data such as LDH, marrow fibrosis, or β2‑microglobulin when applicable to justify transplant candidacy.

Include IPSS score components: marrow blasts, karyotype, and cytopenias per Table PG1.
Note that elevated LDH, marrow fibrosis, or β2‑microglobulin may worsen the prognostic category by one.

Documentation Required

Provide HLA, donor match, and conditioning justification

Include required transplant documentation with authorization submissions: HLA typing and donor match status (HLA‑A, ‑B, ‑DR loci) and a clear justification for chosen conditioning intensity based on age, comorbidities, and performance status.

Provide HLA typing results and donor matching details (ideally 6/6 HLA‑A, ‑B, ‑DR).
Document rationale for MAC vs RIC (age, HCT‑CI, Karnofsky or performance status, organ dysfunction, prior therapies).

Billing Rule

Coding and coverage verification required

Coding and documentation note: the coding lists in the policy may not be all‑inclusive and listing a code does not guarantee coverage; final claim processing is determined by the member's benefit contract and eligibility.

Verify member benefits and eligibility on date of service; inclusion of a code in the policy is informational only.
Not all covered services are eligible for separate reimbursement.

Note

Other provider actions not specified

Not specified in the provided excerpts: no additional operational provider actions or requirements beyond documentation, authorization, and coding verification are detailed.

Policy history and administrative updates are recorded, but no new operational requirements are present in the cited excerpts.

Documentation Required

Record prior non‑transplant therapies

When submitting cases, document prior use or consideration of non‑transplant therapies if clinically relevant, as these are acknowledged management options prior to transplant consideration.

Examples include prior supportive care measures, hypomethylating agents, growth factors, or ruxolitinib/fedratinib for myelofibrosis.
This context may support timing and medical necessity for proceeding to allo‑HCT.

Documentation Required

Document clinical justification for conditioning intensity

The policy provides guidance that conditioning intensity should be tailored to risk; document clinical factors (age, comorbidities, performance status, HCT‑CI) that justify selection of RIC or MAC for the individual.

RIC may reduce non‑relapse mortality in older or more comorbid individuals but may have higher relapse risk compared with MAC.
Record the specific clinical rationale supporting chosen conditioning strategy.

Step Therapy

No step‑therapy requirements specified

No step‑therapy requirements are described in the provided policy excerpts; the policy does not mandate sequencing of therapies prior to allo‑HCT.

Policy states 'Not specified' for step therapy and records no required sequencing.
Providers should document clinical justification for proceeding to transplant without prior specific step‑therapy when appropriate.

Denial Risk

Investigational procedures may be denied if guidelines not met

Allo‑HCT that does not meet the Policy Guidelines criteria is considered investigational and may be denied; ensure submitted cases meet disease‑ and patient‑related criteria in the policy guidelines.

Verify indications such as IPSS intermediate‑2/high risk, increasing blasts, high‑risk cytogenetics, transfusion dependence, or progression to myelofibrosis/AML.
Cases outside guideline criteria should be anticipated to be considered investigational.

Documentation Required

Document donor suitability and matching

Donor suitability must be documented; donor incompatibility or high GVHD risk with haploidentical or poorly matched donors may affect suitability and could lead to denial if an acceptable donor is not identified.

Preferred donors: HLA‑identical sibling matched at HLA‑A, ‑B, and ‑DR (6/6).
Document donor match status and any measures to mitigate GVHD risk when using haploidentical or mismatched donors.

Definitions and Guideline References

inv-33: Myeloid neoplasms / subtypes

Myelodysplastic syndromes (MDS)Includes MDS with defining genetic abnormalities, MDS with low blasts, MDS with increased blasts (e.g., MDS-IB1/IB2), MDS with fibrosis, and MDS-5q

Myeloproliferative neoplasms (MPN)Includes CML (BCR-ABL1+), chronic neutrophilic leukemia, polycythemia vera, and other WHO-defined MPN subtypes

MDS/MPN overlap disordersIncludes entities such as chronic myelomonocytic leukemia (CMML) and other overlap syndromes per WHO classification

Childhood MDSPediatric MDS subtypes recognized under WHO classification

Secondary myeloid neoplasmsMyeloid neoplasms occurring secondary to prior therapy or other causes as classified by WHO

inv-34: Reduced-intensity conditioning (RIC) definition

DefinitionA conditioning regimen with lower intensity than myeloablative conditioning (MAC) used for individuals at high risk of intolerance to conventional myeloablative regimens (e.g., age >60 years, significant comorbidities, low performance status).

PurposeReduce immediate treatment‑related morbidity and non‑relapse mortality while relying on graft‑versus‑malignancy effect to control disease.

Candidate indicationsTypically considered for older patients (often >60 years) or those with organ dysfunction, prior intensive chemotherapy, or low Karnofsky Performance Status.

inv-35: allo-HCT definition

DefinitionAllogeneic hematopoietic cell transplantation (allo‑HCT): infusion of hematopoietic stem cells from a donor to restore bone marrow and immune function; immunologic compatibility (HLA matching) is critical.

Donor sourcesDonor stem cells may be harvested from bone marrow, peripheral blood, or umbilical cord blood.

Key considerationHLA matching at HLA‑A, -B, and -DR loci is important for donor selection and transplant success.

inv-36: Conventional (MAC) conditioning definition

DefinitionMyeloablative conditioning (MAC): high‑dose cytotoxic chemotherapy with or without total body irradiation intended to ablate recipient bone marrow prior to transplant.

MechanismBenefit from initial eradication of malignant cells plus subsequent graft‑versus‑malignancy effect; associated with higher toxicity and requires medically fit candidates.

Typical agentsExamples include cyclophosphamide and busulfan, with or without total body irradiation.

inv-37: RIC — summary definition for older or comorbid individuals

Summary definitionRIC is a lower‑intensity conditioning approach used as a risk‑adapted strategy for older or comorbid individuals who cannot tolerate MAC; it aims to reduce non‑relapse mortality while accepting a potential increase in relapse risk.

Typical candidacyIndividuals typically >60 years or with significant comorbidities, organ dysfunction, prior intensive chemotherapy, or low Karnofsky Performance Status.

Clinical rationaleSelected to allow curative‑intent allo‑HCT in patients who would be ineligible for full myeloablative regimens due to frailty or comorbidity burden.

inv-38: Myeloablative conditioning (MAC) — description

DescriptionMyeloablative conditioning (MAC) involves administration of cytotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to cause bone marrow ablation.

Patient selectionUsed for medically fit individuals able to tolerate substantial adverse effects including risk of opportunistic infections and organ damage.

Therapeutic effectCombines eradication of malignant cells and graft‑versus‑malignancy immune effects; considered the more intensive approach prior to allo‑HCT.

inv-39: Reduced-intensity conditioning (RIC) — pretransplant regimens using lower doses

DefinitionPretransplant regimens using lower doses of cytotoxic drugs or less intense radiotherapy intended to be nonmyeloablative, aiming to reduce treatment‑related morbidity while allowing graft‑versus‑malignancy effect.

Intensity spectrumRIC regimens range from nearly myeloablative to minimally myeloablative with lymphoablation; intensity is tailored to disease and patient condition.

GoalBalance reduction in non‑relapse mortality against potential increased relapse risk to enable allo‑HCT in higher‑risk or frailer patients.

inv-40: NCCN guidelines — referenced guideline sources

NCCN — MDSNCCN Clinical Practice Guidelines in Oncology: Myelodysplastic Syndromes (Version 1.2026) cited in policy references.

NCCN — MPNNCCN Clinical Practice Guidelines in Oncology: Myeloproliferative Neoplasms (Version 2.2025) cited in policy references.

Use in policyNCCN guidelines are listed among references supporting indications and conditioning approach decisions for allo‑HCT.

inv-41: ASTCT guidelines — referenced guideline sources

ASTCT guidelines — indicationsKanate et al. and other ASTCT guidance documents cited (e.g., 2020, 2022, 2023) are included in policy references for HCT indications and practice guidance.

ASTCT evidence reviewsASTCT evidence-based reviews on HCT in MDS and pediatric MDS/AML support transplant indications and conditioning choices.

Role in policyASTCT documents cited as sources informing transplant indications, conditioning selection, and practice guidelines referenced in the policy.

Clinical Background

Background: Myeloid neoplasms — including myelodysplastic syndromes (MDS), myeloproliferative neoplasms (MPN), and related entities — are classified per World Health Organization criteria and prognostically stratified using the International Prognostic Scoring System (IPSS). Risk stratification for MDS (IPSS variables such as marrow blast percentage, cytogenetics/karyotype score, and cytopenias) is required to assess transplant candidacy. Allo‑HCT is the only potentially curative therapy for many of these disorders; choice of conditioning intensity (conventional myeloablative conditioning versus reduced‑intensity conditioning (RIC)) is guided by disease risk, age, comorbidities, and performance status.