CurrentCentenePolicy CP.MP.141

Nonmyeloablative Allogeneic Stem Cell Transplants

Defines medical necessity criteria and non-supported indications for nonmyeloablative / reduced-intensity conditioning allogeneic hematopoietic stem cell transplants, lists relevant CPT/HCPCS procedure codes, and documents revision history and coding implications for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyNonmyeloablative Allogeneic Stem Cell Transplants

Policy CodePolicy CP.MP.141

Change TypeAnnual review updates (additions, threshold revision, clarifications)

Effective Date

Next Review Date

Key ActionDocument that the member is a candidate for allogeneic transplant with a listed diagnosis and unsuitable for myeloablative conditioning due to specified organ dysfunction or comorbidities, including relevant test results (bilirubin, INR, EF, FEV1, DLCO, performance scores).

SourceLink

POLICY UPDATE CHANGES

Added Hodgkin lymphoma to Criteria I.A.9.

Updated DLCO threshold in Criteria I.B.4.b. from ≤ 50% to ≤ 60% predicted.

Added familial bone marrow failure syndromes to indications (I.A.4) and added polycythemia vera to myeloproliferative neoplasms.

Removed absolute contraindications in Criteria I.C. and removed ICD-10 sickle cell codes from ICD-10 table.

Replaced 'experimental/investigational' verbiage in exclusions with descriptive language and organized unsupported indications into three subcategories: solid tumors, autoimmune disorders, hemoglobinopathies.

14Covered Indications Listed

3Exclusion Categories

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13Referenced CPT/HCPCS Codes

Coverage Summary

This policy (CP.MP.141) defines medical necessity criteria and exclusions for Nonmyeloablative / Reduced-Intensity Allogeneic Hematopoietic Stem Cell Transplantation. It lists specific covered diagnoses and objective eligibility thresholds and documents that the policy is CURRENT. Coverage stance is mixed (some indications are medically necessary; other indications are not supported).

Scope includes: defining when nonmyeloablative/RIC allogeneic transplants are medically necessary for listed hematologic and metabolic disorders and when they are not supported, plus associated coding guidance for CPT/HCPCS and requirements for documentation and preauthorization.

Medically Necessary (Coverage) Criteria

Nonmyeloablative/reduced-intensity conditioning (RIC) allogeneic transplants are medically necessary when ALL of the following are met:

ref

Not Supported (Coverage Exclusions / Not Medically Necessary)

Current evidence does not support use of nonmyeloablative/RIC allogeneic transplants for any of the following indications:

ALL of the following

Solid tumors (examples listed)
- Brain tumors
- Ovarian epithelia and mixed epithelial/germ cell cancers
- Primitive neuroectodermal tumors (PNET), including medulloblastoma and ependymoma
- Renal cell carcinoma
- Testicular cancer
- Wilms tumor

Exclusions and unsupported indications were reorganized and clarified in recent annual reviews to group unsupported uses into three subcategories (solid tumors, autoimmune disorders, and hemoglobinopathies) and to replace prior 'experimental/investigational' phrasing with more descriptive language. Editorial clarifications were made to maintain the original coverage intent while improving readability and organization.

Coding

Referenced HCPCS / S codes (informational)HCPCS

S2142	Cord blood-derived stem-cell transplantation, allogeneic
S2150	Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; inclusive global code

Billing Rule

Use current CPT/HCPCS coding guidance

Providers should reference most up-to-date professional coding guidance; the codes listed are informational and inclusion or exclusion does not guarantee coverage.

38204
38205
38207
38208
38209
38210
38211
38212
38213
38214
38215
38230
38240
S2142

Provider Actions

Prior Authorization

Preauthorization requirement implied

Transplants governed by this clinical policy require application of the policy's medical necessity criteria prior to authorization per Health Plan processes (policy serves as guide to medical necessity). The policy's medical necessity criteria must be applied before granting preauthorization.

Documentation Required

Diagnosis and eligibility documentation

Document member is a candidate for allogeneic transplant with one of the listed diagnoses and that they are unsuitable for myeloablative conditioning due to specified organ dysfunction or comorbidities, including relevant test results (bilirubin, INR, EF, FEV1, DLCO, performance scores).

Background

Nonmyeloablative or reduced-intensity conditioning regimens are less intensive preparative approaches that do not fully ablate hematopoiesis and rely more on immunosuppression to permit donor engraftment. They are used to reduce morbidity and mortality associated with high‑dose myeloablative conditioning and are particularly considered for patients with significant comorbidities, advanced age, prior aggressive therapy, or organ dysfunction that make conventional myeloablative regimens unsuitable.

Medicare Determinations

Determination	Effective Date / Type
Stem cell transplantation (formerly 110.8.1) (110.23)	2024-03-06 / NCD

Revision History

01/26addedLatest

Added Hodgkin lymphoma to Criteria I.A.9; updated verbiage in Criteria I.A.10.a; coding and descriptions reviewed; references reviewed and updated; reviewed by internal and external specialists.

02/24revised

Updated DLCO threshold in Criteria I.B.4.b. from ≤ 50% to ≤ 60% predicted; added polycythemia vera to myeloproliferative neoplasms; removed Hodgkin's lymphoma earlier (per NCCN) in that review; removed absolute contraindications in Criteria I.C.; references reviewed and updated; reviewed by internal and external specialists.

Policy Summary

PayerCentene

PolicyNonmyeloablative Allogeneic Stem Cell Transplants

Policy CodePolicy CP.MP.141

Change TypeAnnual review updates (additions, threshold revision, clarifications)

Effective Date

Next Review Date

SourceLink

On This Page

Multiple myeloma (except in tandem transplant - refer to CP.MP.162)

Autoimmune disorders (examples listed)

Multiple sclerosis
Rheumatoid arthritis
Juvenile idiopathic arthritis
Systemic lupus erythematosus
Systemic sclerosis
Dermatomyositis
Polymyositis
Scleroderma

Hemoglobinopathies (examples listed)

Thalassemias
Sickle cell anemia

Added familial bone marrow failure syndromes to indications (I.A.4); rephrased 'aplastic anemia' to 'acquired bone marrow failure such as severe aplastic anemia'; reorganized non-supported indications into solid tumors, autoimmune disorders, and hemoglobinopathies; replaced 'experimental/investigational' verbiage with descriptive language; removed ICD-10 sickle cell codes from ICD-10 table.

02/22clarified

Rephrased criteria language (I.A.3), added familial bone marrow syndromes, added criteria points 13 and 14 to I.A., replaced 'experimental/investigational' verbiage in criteria II. with descriptive language, sorted non-supported indications into three subcategories, and removed ICD-10 sickle-cell disorder codes from supporting tables; references reviewed and updated.

annual reviews 2022-2024removed

Administrative/coding cleanup across reviews including removal of absolute contraindications in Criteria I.C. and removal of ICD-10 sickle cell codes from ICD-10 table.

multiple prior annual reviewsclarified

Editorial and clarifying changes: reorganized unsupported indications and replaced 'experimental/investigational' wording with descriptive exclusions for solid tumors, autoimmune disorders, and hemoglobinopathies without altering coverage intent.