Prior authorization required; investigational HCT codes identified

Prior authorization is required for hematopoietic cell transplantation (HCT) services per payer product variations and the policy coding section; the policy identifies specific HCT procedure codes as investigational for epithelial ovarian cancer and these codes should be included when requesting authorization.

• Investigational procedure codes listed: 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, S2140, S2142

Obtain authorization per payer product requirements

Obtain prior authorization per Capital BlueCross procedures before performing transplant services; administrative and coding review notes indicate authorization is required for applicable products.

• Policy applicability varies by product and program; follow member benefit information and Capital BlueCross authorization processes.

Document prior use of standard cytoreductive surgery and platinum–taxane chemotherapy

Standard-of-care management for advanced epithelial ovarian cancer is cytoreductive surgery plus platinum- and taxane-based systemic chemotherapy; these established therapies are the accepted treatments prior to considering experimental approaches such as HCT.

• Preferred systemic regimen noted: paclitaxel plus a platinum analogue (e.g., cisplatin).
• Cytoreductive surgery with chemotherapy is current management for advanced disease.

Include investigational procedure codes in authorization and clinical rationale

Include the specific procedure codes from the policy’s investigational coding list in authorization requests and clinical documentation to support review; the coding section explicitly identifies which HCT codes are investigational for epithelial ovarian cancer.

• Use the investigational code list when submitting requests (see codes listed in policy).
• Coding lists may not be all-inclusive and are subject to change; include clinical rationale with codes.

Follow current policy statement and coding guidance (policy history reviewed)

Follow the current policy statements and coding guidance when requesting authorization; policy history and administrative updates show the statements and coding were reviewed and should be followed as of the latest consensus review.

• Policy history entries note multiple consensus reviews with 'No changes to policy statement' and coding reviewed.
• Administrative update 11/20/2024 removed an NCCN statement; rely on the current policy text and coding guidance.

Denial risk: HCT requests for epithelial ovarian cancer are investigational and will be denied

Requests for autologous or allogeneic HCT to treat advanced-stage epithelial ovarian cancer will be denied as investigational because the evidence does not demonstrate improved health outcomes.

• Policy statement: autologous and allogeneic HCT are considered investigational for advanced-stage epithelial ovarian cancer.
• Randomized trials have not demonstrated a benefit from HCT in this population compared with conventional therapy.

Reference: CMS NCD for Stem Cell Transplantation (110.23)

Refer to the Centers for Medicare & Medicaid Services National Coverage Determination (NCD) for Stem Cell Transplantation (110.23) as a cited reference that may inform coverage and coding decisions for transplant indications.

• CMS NCD cited: National Coverage Determination (110.23, formerly 110.8.1).
• Use CMS NCD and cited guidelines for additional coverage context when preparing requests.

Refer to NCCN HCT recipient evaluation and GVHD guidance

Refer to NCCN Hematopoietic Cell Transplantation guideline content for pre‑transplant recipient evaluation and graft‑versus‑host disease management when HCT is being considered for other indications; the policy cites the NCCN HCT Pre‑Transplant Recipient Evaluation guideline.

• NCCN guideline cited: Hematopoietic Cell Transplantation (HCT): Pre‑Transplant Recipient Evaluation and Management of Graft‑Versus‑Host Disease, Version 2.2025.

Consult NCCN pre‑transplant recipient evaluation guidance

The policy cites the NCCN Hematopoietic Cell Transplantation guideline (Pre‑Transplant Recipient Evaluation), which contains recommended evaluation elements; consult that guideline for specific pre‑transplant evaluation steps.

• See NCCN HCT guideline (Version 2.2025) for recommended evaluation elements.

Confirm product‑specific applicability before submitting requests

Policy applicability varies by product and program; confirm whether this policy applies to the member's specific Capital BlueCross product (for example, FEP PPO directs providers to the FEP medical policy manual).

• FEP PPO: refer to the FEP medical policy manual at fepblue.org for benefit-specific guidance.

Consider transplant center standards and national coverage guidance

NCCN and the CMS NCD are cited in the policy and suggest that transplant center standards and national coverage policies are relevant to decision-making; providers should ensure center practices align with applicable national guidance when applicable.

• Policy references include NCCN HCT guidelines and the CMS NCD for Stem Cell Transplantation.