CurrentCapital BluecrossPolicy MP 9.046

Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia

Defines medical necessity and investigational indications for autologous and allogeneic hematopoietic cell transplantation (HCT) for members with Waldenström macroglobulinemia covered by Capital BlueCross products, with product-specific variations noted.

Policy Summary

PayerCapital Bluecross

PolicyHematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia

Policy CodePolicy MP 9.046

Change TypeAdministrative updates (ICD-10 code changesremoved NCCN statement)

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionUse listed procedure and diagnosis codes when requesting prior authorization; autologous HCT may be considered medically necessary as salvage therapy for chemosensitive WM while allogeneic HCT is investigational.

SourceLink

POLICY UPDATE CHANGES

Added ICD-10 codes C88.00 and C88.01 and removed ICD-10 code C88.0.

Removed NCCN statement.

C88.00, C88.01ICD-10 codes added

~1,500estimated new WM cases annually

68.5%5-year OS (autologous HCT)

52%5-year OS (allogeneic HCT)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

02/27/2020-01/30/2025policy history span

Coverage criteria for hematopoietic cell transplantation

Coverage criteria (not present in this extract)

Covered when medically necessary:

ALL of the following

Autologous hematopoietic cell transplantation (HCT) as salvage therapy for patients with chemosensitive Waldenstrom macroglobulinemia is considered medically necessary.
Allogeneic hematopoietic cell transplantation is considered investigational for Waldenstrom macroglobulinemia due to insufficient evidence to determine effects on health outcomes.
Clinical input and national/international guidelines support autologous HCT as salvage therapy for chemosensitive disease; evidence is primarily from case series and registry analyses showing limited patient numbers and lack of controlled studies.

Procedure and diagnosis codes

Investigational; therefore, not covered (Procedure Codes)CPTNot Covered

38205
38230
38240
38242

Covered when medically necessary (Procedure Codes)CPT | HCPCSCovered

38213
38206
38214
38207
38215
38208
38232
38209
38241
38210

1–10 of 14

1/2

Relevant Diagnosis CodesICD-10

C88.00	Waldenstrom macroglobulinemia not having achieved remission
C88.01	Waldenstrom macroglobulinemia, in remission

Procedure CodesCPT

38206	Procedure code (as listed)
38207	Procedure code (as listed)
38208	Procedure code (as listed)
38209	Procedure code (as listed)
38210	Procedure code (as listed)
38211	Procedure code (as listed)
38212	Procedure code (as listed)
38213	Procedure code (as listed)
38214	Procedure code (as listed)
38215	Procedure code (as listed)

1–10 of 14

1/2

ICD-10 CodesICD-10

C88.00	Waldenstrom macroglobulinemia not having achieved remission
C88.01	Waldenstrom macroglobulinemia, in remission
C88.0	Previously listed ICD-10 code removed

Prior authorization, documentation, and provider guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for hematopoietic cell transplantation for Waldenstrom macroglobulinemia. Documentation should demonstrate that autologous HCT is being requested as salvage therapy for chemosensitive disease after appropriate prior systemic therapies, and that allogeneic HCT requests include rationale; note that allogeneic HCT is considered investigational for WM and is likely to be denied. Coding and documentation should follow the listed procedure and diagnosis codes. The code list may not be all-inclusive and codes are subject to change; presence of a code here does not guarantee coverage under the member's benefit plan.

Prior authorization required; provide clinical justification and prior therapy history.
Autologous HCT: may be considered medically necessary as salvage therapy for chemosensitive WM when criteria met.
Allogeneic HCT: investigational for WM — requests will be reviewed and are expected to be denied absent compelling evidence.
Coding list is informational only; verify member benefits for coverage determinations.

Clinical background and disease overview

Waldenström macroglobulinemia (WM) is a B‑cell lymphoplasmacytic lymphoma characterized by an IgM monoclonal gammopathy. It most commonly presents in older adults; reported median patient age ranges approximately 63–68 years. Median survival is in the order of 5–10 years, and treatment is indicated for symptomatic disease (for example, anemia, thrombocytopenia, organomegaly, hyperviscosity, neuropathy, amyloidosis, cryoglobulinemia, or cold‑agglutinin disease).

Key definitions and terms

Waldenström macroglobulinemia (WM)

DefinitionRevised WHO/European classifications recognize WM as a lymphoplasmacytic lymphoma with associated IgM monoclonal gammopathy and characteristic bone marrow infiltration; no minimum serum IgM concentration is required for diagnosis.

Typical patient demographicsMedian age 63–68 years; men comprise ~55%–70% of cases.

Clinical indications for treatmentTherapy indicated for symptomatic patients (anemia, thrombocytopenia, organomegaly, symptomatic hyperviscosity, severe neuropathy, amyloidosis, cryoglobulinemia, cold‑agglutinin disease, or transformation).

Diagnostic requirementCharacteristic pattern of bone marrow infiltration with small lymphocytes demonstrating plasmacytic differentiation.

Reduced‑intensity conditioning (RIC)

Definition

Patient candidate and timing criteria for HCT

Candidate criteria

Candidate and timing context for HCT in WM

Autologous candidate: Patient has chemosensitive Waldenstrom macroglobulinemia and is being considered for salvage/autologous HCT after prior systemic therapy.chemosensitive disease/remission

Autologous HCT is typically performed as consolidation when disease is in complete remission; prior systemic therapies commonly include rituximab-based combinations and may include purine analogs.

Contraindications

Contraindications to hematopoietic cell transplantation are not explicitly listed in the sections of the policy provided.

Pre-transplant evaluation and testing

Documentation Required

Evaluation requirements — document chemosensitivity and prior therapies

Standard pretransplant evaluation must document assessment of chemosensitivity and prior systemic therapies (including rituximab-based regimens and purine analogs) and suitability for high‑dose therapy and stem cell collection.

Document evidence of chemosensitive disease or remission before autologous HCT.
Record prior systemic therapies (e.g., rituximab combinations, bendamustine, purine analogs) in the authorization documentation.

Transplant center and facility requirements

Note

Center requirements

Center requirements are not specified in this section of the policy.

Post-transplant monitoring and coverage

Post‑transplant monitoring and supportive care

Infection/toxicity riskPatients undergoing autologous HCT are susceptible to chemotherapy‑related toxicities and opportunistic infections prior to engraftment.

Graft‑versus‑host diseaseGraft‑versus‑host disease is not applicable to autologous HCT.

Purpose of autologous HCTAutologous HCT is typically performed as consolidation therapy when disease is in complete remission after cytotoxic therapy to eradicate malignant cells and permit marrow repopulation.

Supportive care implicationPost‑transplant monitoring and supportive care should address pre‑engraftment infection risk and chemotherapy toxicities.

Hematopoietic cell transplantation

Scope of policy

Policy revision history

2024-10-01administrative

ICD-10 codes updated: added C88.00 and C88.01 and removed ICD-10 code C88.0; effective date recorded.

2024-11-20administrativeLatest

Administrative update recorded removing NCCN statement from policy history.

Policy Summary

PayerCapital Bluecross

PolicyHematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia

Policy CodePolicy MP 9.046

Change TypeAdministrative updates (ICD-10 code changesremoved NCCN statement)

Effective DateJul 1, 2025

Next Review DateN/A

SourceLink

On This Page

Documentation Required

Coding and Documentation Note

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Ensure claims and authorization requests use the appropriate procedure and diagnosis codes and include supporting documentation linking the codes to the clinical indication.

Procedure / CPT-like codes (examples from source): 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38232, 38241, 38243, S2150.
ICD-10 diagnosis codes: C88.00 (Waldenstrom macroglobulinemia not having achieved remission), C88.01 (Waldenstrom macroglobulinemia, in remission).
Coding updates: codes are periodically reviewed and updated (see Policy History for recent ICD-10 additions and removals).

Billing Rule

Provider Coding/Documentation Guidance

Coding and documentation should follow the listed procedure and diagnosis codes; note that the code listing is not all-inclusive and presence of a code here does not denote coverage. Providers should reference the member's benefit plan for coverage and include all pertinent clinical notes, prior treatment history, and indication (chemosensitivity, salvage intent) with the authorization request.

Include prior systemic therapy history (e.g., rituximab-based regimens, bendamustine, bortezomib, purine analogues) when requesting authorization for autologous HCT.
Attach relevant pathology, response assessments, and documentation of chemosensitivity.
Use ICD-10 codes C88.00 or C88.01 as appropriate to the patient's disease status.

Reduced-intensity conditioning (RIC) refers to pretransplant regimens using lower doses or less intense cytotoxic drugs or radiotherapy than conventional myeloablative conditioning, intended to reduce treatment-related morbidity and non-relapse mortality while relying on graft‑versus‑malignancy effects.

PurposeReduce disease burden while minimizing peri-transplant morbidity and non-relapse mortality as donor graft effects develop.

Intensity continuumRIC regimens lie on a continuum from nearly myeloablative to minimally myeloablative with lymphoablation and are tailored to disease and patient condition.

Post‑engraftmentPatients initially demonstrate mixed chimerism and most convert to full donor chimerism; donor lymphocyte infusions may be used to eradicate residual disease.

C88.00

ICD-10 codeC88.00

DescriptionWaldenstrom macroglobulinemia not having achieved remission.

Use noteListed among diagnosis codes for hematopoietic cell transplantation authorization and coding in this policy.

C88.01

ICD-10 codeC88.01

DescriptionWaldenstrom macroglobulinemia, in remission.

Use noteListed among diagnosis codes for hematopoietic cell transplantation authorization and coding in this policy.

Pertains to hematopoietic cell transplantation (autologous and allogeneic) for Waldenstrom macroglobulinemia as reflected by cited literature and coding.

Coverage stance summaryAutologous HCT may be considered medically necessary as salvage therapy for chemosensitive WM; allogeneic HCT is considered investigational.

Policy identifierMP 9.046.

Coding linkageProcedure and diagnosis codes listed in the policy should be used for authorization and billing (see coding section).