Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesHematology/OncologyCentene Donor Lymphocyte Infusion Coverage | OpenP…
    Ask Trek AI about this page
    CurrentCentenePolicy CP.MP.101

    Donor Lymphocyte Infusion

    Customize your policy alerts

    Sign up for Centene Policy CP.MP.101 alerts

    Get alerted when Policy CP.MP.101 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Medical necessity criteria and coverage guidance for donor lymphocyte infusion (DLI) following allogeneic hematopoietic stem cell transplantation (HSCT) for non‑Medicare Centene-affiliated health plans; includes indications, contraindications, and coding implications.

    Policy Summary
    PayerCentene
    PolicyDonor Lymphocyte Infusion
    Policy CodePolicy CP.MP.101
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and submit appropriate CPT/HCPCS codes with clinical justification demonstrating medical necessity for DLI.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    40-60%GvHD after DLI
    70-80%

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CML complete remission
    15-20%AML remission with DLI alone
    2-5%Bone marrow aplasia risk
    <90% vs 100%Chimerism

    Coverage Criteria for Donor Lymphocyte Infusion (DLI)

    Medically necessary indications

    Covered when ALL of the following are met:

    Primary coverage criteria: 1) Patient has had a prior allogeneic hematopoietic stem cell transplantation (HSCT). 2) Donor lymphocyte infusion (DLI) is requested to treat relapsed or refractory hematologic malignancy after HSCT or to decrease the risk of relapse of a hematologic malignancy (including therapeutic use for relapse and preemptive use for mixed chimerism or detectable minimal residual disease). 3) The request is for a non‑Medicare Centene‑affiliated health plan as specified in the policy.

    Sourced from policy statements I and Description.

    Not medically supported indications / contraindications

    Not covered / contraindicated when ANY of the following are present:

    Contraindications and unsupported uses: A) Use of DLI for indications other than post‑allogeneic HSCT relapse prevention/treatment, including genetic modification or ex vivo manipulation of donor lymphocytes. B) Presence of grade 2 or higher acute graft‑versus‑host disease (GvHD). C) Use solely to increase donor chimerism when there is no clinical risk of relapse (not recommended due to risk of exacerbating GvHD).

    Sourced from policy statements II and Description.

    This policy excludes use of donor lymphocyte infusion (DLI) when there is genetic modification or other ex vivo manipulation of donor lymphocytes and when the patient has grade ≥2 acute graft‑versus‑host disease (GvHD). These exclusions reflect the policy statement that current evidence does not support modified or manipulated donor grafts for DLI outside of clinical trials and that active, clinically significant acute GvHD is a contraindication to DLI because of unacceptable risk.

    Donor lymphocyte infusion (DLI) is considered not supported for indications other than use following an allogeneic HSCT to treat relapse or to decrease relapse risk (including therapeutic and preemptive uses described elsewhere in this policy). Requests for DLI for any other clinical indication do not meet medical necessity criteria and may be denied.

    Clinical Effectiveness and Indications by Diagnosis

    IndicationRegimen / Role of DLIReported response / notes
    Relapsed chronic myeloid leukemia (CML)DLI as single‑modality therapyHigh complete remission rates reported (70–80%); responses often durable
    IndicationRegimen / Role of DLIReported response / notes
    Relapsed acute myeloid leukemia (AML)DLI often used in combination with chemotherapy rather than as sole therapyLower remission rates with DLI alone (~15–20%); combination with chemotherapy commonly necessary to elicit anti‑tumor effect
    IndicationRegimen / Role of DLIReported response / notes
    Relapsed multiple myeloma (MM)DLI used to stimulate graft‑versus‑myeloma (GvM) effect; may be administered post‑allogeneic HSCT or per NCCN guidance on/ off trialVariable response rates reported (~22–52%); outcomes influenced by frequency of autologous vs allogeneic transplants and trial context

    Line of Therapy / Clinical Context

    Salvage — line of therapy criteria

    Line of therapy:

    Therapeutic contexts: DLI is used as salvage therapy for relapsed or refractory disease after allogeneic HSCT and can be used pre‑emptively in high‑risk patients (for example, those with mixed chimerism or detectable MRD).

    Sourced from Description and Clinical Policy discussion of salvage/preemptive use.

    Coding and Procedure Codes

    Referenced procedure codesmixed
    38215Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer.
    38242Allogeneic lymphocyte infusions.
    86950Leukocyte transfusion
    S2150Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and posttransplant care in the global definition
    Reported effective T cell dose range — numeric/key clinical data
    Reported effective T cell dose range0.01 to 8.8 × 10^8 T cells/kg
    Source summaryRange reported from a review of multiple studies (Deol & Lum) summarizing effective cellular doses for DLI.
    Dose contextValues represent T cells per kg of recipient body weight collected via apheresis and infused as donor lymphocyte infusion (DLI).

    Provider Actions, Documentation, and Billing

    Prior Authorization

    Submit prior authorization with CPT/HCPCS and clinical justification

    Prior authorization is required for donor lymphocyte infusion (DLI) and associated procedures. Submit the applicable CPT/HCPCS codes (e.g., 38215, 38242, 86950, S2150) and clinical justification demonstrating medical necessity with the prior authorization request.

    • Include specific procedure codes being requested (38215, 38242, 86950, S2150).
    • Provide clinical justification that meets the policy’s medical necessity criteria (see required documentation).
    Step Therapy

    Document combination therapy context (e.g., AML + chemotherapy)

    When DLI is used for certain diagnoses such as relapsed AML, it is often administered in combination with chemotherapy rather than as a sole modality; documentation should describe prior or concurrent chemotherapy and the treatment rationale.

    • Document prior or concurrent chemotherapy regimens when DLI is part of combination therapy for AML.

    Background

    Donor lymphocyte infusion (DLI) is an adoptive immunotherapy in which lymphocytes from the original allogeneic HSCT donor are collected and infused into the recipient to induce an immune‑mediated graft‑versus‑tumor (GvT) effect. DLI is used to treat relapsed or refractory hematologic malignancies after allogeneic HSCT and may be used preemptively for patients with mixed chimerism or detectable minimal residual disease (MRD) to decrease relapse risk. Major potential complications include graft‑versus‑host disease (GvHD) (occurring in roughly 40–60% of patients), bone marrow aplasia (approximately 2–5%), infection, and bleeding.

    Definitions and Key Terms

    Mixed chimerism
    Definition of mixed chimerism<90% donor cells detected after HSCT
    Clinical relevanceMay indicate incipient relapse risk and can be an indication for pre‑emptive DLI when clinically appropriate.
    Detection methodsDetermined by chimerism testing after engraftment (molecular or immunophenotypic assays).
    Full (complete) chimerism
    Definition of full (complete) chimerism100% donor cells detected after HSCT
    Clinical implicationSuggests complete hematopoietic replacement after engraftment.
    Association with response
    Policy Summary
    PayerCentene
    PolicyDonor Lymphocyte Infusion
    Policy CodePolicy CP.MP.101
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and submit appropriate CPT/HCPCS codes with clinical justification demonstrating medical necessity for DLI.
    SourceLink
    On This Page
    Coverage Criteria for Donor Lymphocyte Infusion (DLI)Clinical Effectiveness and Indications by DiagnosisLine of Therapy / Clinical ContextCoding and Procedure CodesProvider Actions, Documentation, and BillingBackgroundDefinitions and Key Terms
  1. Explain clinical reasoning for combining DLI with chemotherapy (e.g., low single‑agent DLI remission rates in AML).
    2. Documentation Required

    Required clinical documentation to support DLI

    Provide clinical documentation that supports prior allogeneic HSCT, the specific indication for DLI (treatment of relapsed/refractory hematologic malignancy or to decrease relapse risk), and when used preemptively include chimerism or MRD status.

    • Evidence of prior allogeneic hematopoietic stem cell transplantation (HSCT).
    • Clinical notes describing relapse/refractory disease or high risk of relapse (e.g., mixed chimerism or detectable MRD).
    • Any prior or concurrent therapies relevant to the decision to administer DLI.
    Denial Risk

    Do not request DLI for non‑supported indications

    Use of DLI for indications other than following allogeneic HSCT to treat relapsed/refractory hematologic malignancy or to decrease relapse risk is not supported and may be denied.

    • Unsupported indications include genetic modification or ex vivo manipulation of donor lymphocytes.
    • DLI solely to increase donor chimerism without clinical relapse risk is not recommended.
    Denial Risk

    Contraindication: active grade ≥2 acute GvHD — potential denial risk

    Do not administer or request DLI when grade 2 or higher acute graft‑versus‑host disease (GvHD) is present; DLI in this setting is a contraindication and may result in denial.

    • Assess and document GvHD grade prior to DLI; with grade ≥2 acute GvHD, DLI is contraindicated.
    • If GvHD is present, provide documentation if an alternative plan is being considered (note: policy states current evidence does not support DLI in this setting).
    Conversion to full chimerism has been observed with clinical responses to DLI in some patients without GvHD.