Cigna HSCT Coverage & Policy Update

Coverage Summary

This policy (Policy No. 0533, effective 12/15/2025) defines Cigna's coverage criteria for hematopoietic stem cell transplantation (HSCT/HCT) — both autologous and allogeneic — across a broad range of hematologic malignancies and related disorders (leukemias, lymphomas, myeloma, MDS, myelofibrosis, POEMS, systemic mastocytosis, PCNSL, and others). Coverage is mixed: many disease-specific indications are covered when specified criteria are met, while some procedures or scenarios are considered experimental/investigational or not medically necessary. The policy incorporates guideline-based recommendations (NCCN, ASTCT/ASBMT/ASCTT and recent consensus statements) and lists medically necessary procedure CPT/HCPCS codes when criteria are satisfied. It also references applicable Medicare determinations (NCD STEM CELL Transplantation, formerly 110.8.1) and emphasizes plan document and benefit-specific application of the coverage rules. The statistics summary highlights that multiple indications are covered with criteria, several procedures remain experimental/investigational, and key guideline sources include NCCN, ASTCT, and ASBMT.

Medical-Necessity Criteria (by indication)

General requirement for allogeneic transplantations

All allogeneic transplantations must be from an appropriately matched human leukocyte antigen (HLA) donor.

Allogeneic transplantations must be from an appropriately matched HLA donor.

Acute Lymphoblastic Leukemia (ALL) - Allogeneic HSCT considered medically necessary

Allogeneic hematopoietic stem-cell transplantation (HSCT) is considered medically necessary for the treatment of acute lymphoblastic leukemia (ALL) when ANY of the following criteria are met:

failed induction therapy

second or subsequent remission

B-cell lineage ALL with marrow relapse while on treatment or within six months of completing treatment

T-cell lineage ALL in first or subsequent remission

first remission with poor prognosis or high risk features*

Acute Lymphoblastic Leukemia (ALL) - Second allogeneic HSCT

A second allogeneic HSCT is considered medically necessary for the treatment of ALL when ALL of the following are met:

relapsed disease occurring more than six months after first allogeneic HSCT

Acute Lymphoblastic Leukemia (ALL) - Not medically necessary

HSCT for the treatment of ALL is considered not medically necessary when ANY of the following conditions are present:

active central nervous system (CNS) involvement

presence of any significant comorbid medical or psychiatric illness which would significantly compromise the clinical care and chances of survival

advanced age in an adult

Acute Myeloid Leukemia (AML) - Allogeneic HSCT considered medically necessary

Allogeneic HSCT is considered medically necessary for the treatment of acute myeloid leukemia (AML) when ANY of the following criteria is met:

first remission for an adverse-risk or intermediate-risk* individual

second or subsequent remission

failed induction

no induction treatment and any of the following: antecedent hematological disease; treatment-related secondary AML

Acute Myeloid Leukemia (AML) - Second allogeneic HSCT

A second allogeneic HSCT is considered medically necessary for the treatment of AML when BOTH of the following criteria are met:

relapse of disease occurring more than six months after first allogeneic HSCT

second or subsequent remission

Acute Myeloid Leukemia (AML) - Allogeneic HSCT for blastic plasmacytoid dendritic cell neoplasm

Allogeneic HSCT is considered medically necessary for the treatment of blastic plasmacytoid dendritic cell neoplasm following complete remission.

Allogeneic HSCT is medically necessary following complete remission.

Acute Myeloid Leukemia (AML) - Autologous HSCT

Autologous HSCT is considered medically necessary for the treatment of AML when allogeneic HSCT is not available or is not appropriate and EITHER of the following criteria is met:

first remission for a favorable/intermediate risk* individual

second or subsequent remission

Amyloidosis (systemic light-chain) - Autologous HSCT

Autologous HSCT is considered medically necessary for the treatment of amyloidosis (systemic light-chain) when ALL of the following are met:

absence of severe or multiple comorbidities that would increase risk of poor result or death

Amyloidosis (systemic light-chain) - Experimental / Unproven

The following are considered experimental, investigational or unproven for systemic light-chain amyloidosis:

second autologous HSCT for recurrent or refractory disease

tandem autologous HSCT

Chronic Lymphocytic Leukemia (CLL) - Allogeneic HSCT

Allogeneic HSCT is considered medically necessary for the treatment of chronic lymphocytic leukemia (CLL) when the disease is not responsive to standard therapy.

Allogeneic HSCT is medically necessary when CLL is not responsive to standard therapy.

Chronic Myeloid Leukemia (CML) - Allogeneic HSCT considered medically necessary

Allogeneic HSCT is considered medically necessary for the treatment of chronic myeloid leukemia (CML) in ANY of the following:

hematologic remission not reached after three months of tyrosine kinase inhibitor (TKI) therapy

no cytogenetic response or cytogenetic relapse at 6, 12, or 18 months after achieving initial hematologic remission following three months of TKI therapy

molecular remission not reached by 12 months of TKI therapy

disease progression on TKI therapy to accelerated phase or blast crisis

an individual who is not a candidate for TKI therapy

Chronic Myeloid Leukemia (CML) - Autologous HSCT

Autologous HSCT for the treatment of CML is considered experimental, investigational or unproven.

Autologous HSCT is experimental, investigational or unproven for CML.

Chronic Myelomonocytic Leukemia (CMML)

Allogeneic HSCT is considered medically necessary for the treatment of chronic myelomonocytic leukemia (CMML). Autologous HSCT for CMML is experimental, investigational, or unproven.

Allogeneic HSCT is medically necessary for CMML

Autologous HSCT is experimental, investigational, or unproven for CMML

Hodgkin Lymphoma - HSCT

Autologous HSCT is considered medically necessary for the treatment of refractory, primary progressive or recurrent Hodgkin lymphoma. Allogeneic HSCT is considered medically necessary when the individual is not a candidate for autologous HSCT or in the setting of a failed autologous transplant.

Autologous HSCT medically necessary for refractory, primary progressive or recurrent Hodgkin lymphoma

Allogeneic HSCT medically necessary when autologous not candidate or failed autologous transplant

Juvenile Myelomonocytic Leukemia (JMML)

Allogeneic HSCT is considered medically necessary for the treatment of juvenile myelomonocytic leukemia (JMML). Autologous HSCT for JMML is experimental, investigational, or unproven.

Allogeneic HSCT is medically necessary for JMML

Autologous HSCT is experimental, investigational, or unproven for JMML

Multiple Myeloma (MM) - Autologous HSCT

Autologous HSCT for the treatment of active (i.e., symptomatic) multiple myeloma (MM) is considered medically necessary.

Autologous HSCT is medically necessary for active (symptomatic) MM

Multiple Myeloma (MM) - Second autologous HSCT

A second autologous HSCT for the treatment of active (symptomatic) MM is considered medically necessary when ANY of the following are met:

progressive disease following a previous autologous HSCT

Myelodysplastic Syndromes (MDS) - Allogeneic HSCT

Allogeneic HSCT is considered medically necessary for the treatment of an individual with intermediate- or high-risk* myelodysplastic syndrome (MDS) according to IPSS-R.

Allogeneic HSCT is medically necessary for intermediate- or high-risk MDS (per IPSS-R)

Myelofibrosis - HSCT

Allogeneic HSCT is considered medically necessary for the treatment of myelofibrosis when symptoms persist or worsen despite standard supportive care. Autologous HSCT is experimental, investigational or unproven.

Allogeneic HSCT medically necessary for persistent/worsening symptoms despite supportive care

Autologous HSCT experimental, investigational or unproven for myelofibrosis

Non-Hodgkin Lymphoma (NHL) - HSCT

Non-Hodgkin lymphoma (NHL) HSCT coverage criteria vary by histology, pediatric vs adult status, and prior therapies. Autologous and allogeneic HSCT may be considered in relapsed/refractory settings; specific exclusions apply.

Autologous HSCT may be medically necessary for adults/children with relapsed/refractory NHL per disease-specific guidance

Allogeneic HSCT may be medically necessary for certain NHL subtypes or after failed autologous HSCT

Autologous HSCT for mycosis fungoides/Sézary syndrome (MF/SS) is not medically necessary

Non-Hodgkin Lymphoma (NHL) - Experimental / Unproven

The following are considered experimental, investigational or unproven for NHL:

tandem HCT

stage I disease treated with HCT approaches as primary therapy

POEMS Syndrome - Autologous HSCT

Autologous HSCT is considered medically necessary for POEMS syndrome.

Autologous HSCT is medically necessary for POEMS syndrome

Primary Central Nervous System Lymphoma (PCNSL) - Autologous HSCT

Autologous HSCT is considered medically necessary for primary central nervous system lymphoma (PCNSL) when ANY of the following are met:

relapsed or refractory PCNSL

consolidation in first complete remission (CR1) per guideline-based protocols

Systemic Mastocytosis - Allogeneic HSCT

Allogeneic HSCT is considered medically necessary for systemic mastocytosis for advanced/aggressive disease.

Allogeneic HSCT medically necessary for advanced/aggressive systemic mastocytosis

Contraindications / Relative contraindications

Contraindications and relative contraindications to HSCT include specific organ function thresholds and other absolute/relative exclusions. Preserve thresholds and list other contraindications.

Left ventricular ejection fraction (LVEF) below institutional threshold or clinically significant cardiac dysfunction

total bilirubin, transaminases outside acceptable institutional limits

creatinine clearance (CrCl) below institutional threshold for transplant conditioning

diffusing capacity for carbon monoxide (DLCO) below institutional threshold

Karnofsky performance status or ECOG score indicating inability to tolerate transplant

General HCT considerations / AYA and older adults

General HCT considerations for adolescents/young adults (AYA) and older adults. Use comprehensive assessment and document using HCT-CI where appropriate.

multidisciplinary assessment of candidacy including geriatric/AYA considerations as applicable

assessment and optimization of comorbidities; consider HCT-Comorbidity Index (HCT-CI)

documentation of functional status, psychosocial support, and transplant goals

consideration of donor availability and stem cell collection feasibility

anticipation and management plan for transplant-related complications

NCCN and ASTCT recommendations - Children AML summary

NCCN and ASTCT recommendations for HCT by remission status and risk for pediatric AML — summary:

CR1: consider autologous vs allogeneic based on risk and histology (ANY per guideline)

CR2 or greater, or not in remission: consider allogeneic HSCT

pediatric considerations may differ from adult recommendations; follow disease- and age-specific guidance

Systemic Light Chain Amyloidosis - eligibility summary

Systemic light chain amyloidosis eligibility considerations:

organ involvement severity appropriate for transplant

tumor burden and response to induction

bone marrow plasma cells < 10%

acceptable performance status and organ function

CLL guideline-based summary

CLL guideline-based considerations relevant to allo-HCT candidacy:

del(17p)/TP53 abnormalities may prompt consideration of allo-HCT in sequence with targeted therapies

consider allo-HCT for high-risk CLL after failure of targeted agents per guideline-based sequencing

CML guideline segmentation by pediatric vs adult

CML guidance segmented by pediatric vs adult considerations:

allo-HCT appropriate for TKI failure, progression to accelerated/blast phase, or intolerance to TKIs

autologous HCT is not recommended for CML

Hairy Cell Leukemia - HSCT guidance

Hairy cell leukemia recommendations (ASTCT/NCCN summary):

consider autologous HSCT or other HCT approaches per guideline only in selected relapsed/refractory scenarios as documented by specialty societies

coverage and sequencing depend on prior lines of therapy and remission status

Diffuse Large B-Cell Lymphoma (DLBCL) / High-Grade B-Cell Lymphoma (HGBCL) - recommendations

DLBCL/HGBCL recommendations and exceptions:

autologous HSCT consolidation is not recommended in CR after first-line therapy for DLBCL/HGBCL

exceptions include primary CNS lymphoma consolidation per specific recommendations

consider autologous HSCT or CAR-T for relapsed/refractory disease based on histology and prior therapy

Transplant Eligibility and General Recommendations

Transplant eligibility and general recommendations:

evaluate organ function and performance status prior to referral

refer to transplant center early for donor search and candidacy evaluation

stem cell collection guidance and timing relative to induction and consolidation therapy

Coding

Medicare determinations referencedmixed

NCD STEM CELL Transplantation

National Coverage Determination for Stem Cell Transplantation (Formerly 110.8.1); revision effective 2016-01-27 referenced; advises review of current Medicare policy.

Medically Necessary Procedure Codes (CPT/HCPCS)mixedCovered

38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition.
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic.
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous.
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage.
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor.
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor.
38210	Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion.
38211	Transplant preparation of hematopoietic progenitor cells; tumor cell depletion.
38212	Transplant preparation of hematopoietic progenitor cells; red blood cell removal.
38213	Transplant preparation of hematopoietic progenitor cells; platelet depletion.

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Coding guidance (general)mixed

No codes listed

Policy document - page referencemixed

No codes listed

Policy identifier / internalmixed

No codes listed

Verify that all CPT/HCPCS and diagnosis codes are current and active for the date of service and follow the customer's benefit plan document; claims submitted without covered diagnosis or procedure codes will be denied as not covered. Providers should confirm effective dates and code status per AMA/CMS updates before billing or submitting prior authorization requests.

Provider Actions & Operational Requirements

Billing Rule

Follow plan document and provide covered codes

Follow the plan document and report covered procedure and supply codes when submitting claims or prior authorization requests. Use the most appropriate CPT and HCPCS codes in effect on the date of service; claims submitted without covered codes will be denied as not covered.

Report all listed CPT/HCPCS codes associated with HSCT and related services.
Ensure active code validation against current code sets at time of billing.

Documentation Required

Assess HCT eligibility and comorbidities

Assess hematopoietic cell transplantation (HCT) eligibility and comorbidities during evaluation. Use standardized tools such as the HCT-Comorbidity Index (HCT-CI) to document comorbidity burden and transplant risk.

Background, Guideline & Evidence Summary

Background: HSCT (also called HCT) may be autologous (patient's own stem cells) or allogeneic (donor-derived, ideally HLA matched). Preparative approaches include myeloablative regimens (very high–dose chemo/radiation) and non‑myeloablative/reduced‑intensity regimens (lower intensity to reduce upfront toxicity and permit graft-versus‑tumor effect). HSCT is indicated across many blood cancers — e.g., ALL, AML, CML, CLL, MDS, JMML/CMML, Hodgkin and non‑Hodgkin lymphomas, multiple myeloma, AL amyloidosis, POEMS, myelofibrosis, systemic mastocytosis, and primary CNS lymphoma — with indication and modality depending on disease subtype, remission status, risk category and prior therapies. Health equity considerations are recognized: donor availability and registry composition affect access (notably lower unrelated-donor match likelihood for Black, Hispanic and Asian patients), and ASTCT/NMDP ACCESS initiatives and literature document disparities in referral, time to transplant, donor recruitment, and outcomes among racial/ethnic minorities.

Source	Version or Year	Key recommendation summary
NCCN Hodgkin Lymphoma	2.2025 (Jan 30, 2025)	Maps coverage designations by disease state (eg CR1 PET negative = N/N; primary refractory/resistant = Allogeneic C; Autologous S/N) and recommends HDT/ASCR for eligible relapsed/refractory CHL candidates; pediatric guidance includes Deauville ≤3 criteria for proceeding to HDT/ASCR.
NCCN CNS Cancers (PCNSL)	V.1.2025 (June 3, 2025)	For newly diagnosed PCNSL after induction HD‑methotrexate: consolidation options include high-dose chemo + stem cell rescue (eg TBC or thiotepa-containing regimens) or low‑dose WBRT; for relapsed/refractory disease stem cell rescue may be considered (category 2B) only with CR/PR to reinduction and prior response/time-to-relapse ≥1 year for retreatment.
ASTCT Clinical Practice Recommendations	2022	Consensus statements for MM: recommend early autologous HCT after 4–6 cycles (Grade A*); guidance on salvage/second autologous HCT, role of CAR‑T, and generally do not recommend allogeneic HCT outside trials.
ASBMT / Epperla et al.	2023	DLBCL/HGBCL recommendations: do NOT recommend routine autologous HCT consolidation in PET‑negative CR after first‑line therapy (Grade A); recommend autologous HCT consolidation for eligible PCNSL in CR1 and thiotepa‑containing conditioning (Grade A/B).
McLornan / EBMT	2024	Best practice recommendations for allogeneic HCT in advanced systemic mastocytosis; consider allo‑HCT after adequate response or for inadequate response after re‑staging.
NCCN Multiple Myeloma / ASTCT MM statements	NCCN 2.2025 / ASTCT 2022	NCCN: assess all SLCA patients for autologous HCT eligibility; preferred option for selected patients (<10% marrow involvement, single vital organ, good PS). ASTCT: early autologous consolidation, maintenance recommendations and limited role for allo‑HCT.
ASTCT / USCLC MF/SS guidance	2025 (Goyal et al.)	Recommends referral for allo‑HCT consideration in MF/SS with stage IIB+ refractory/progressive disease after ≥2 systemic lines, ideally in CR or at least PR at time of allo‑HCT; does NOT recommend auto‑HCT for CTCL.
ASTCT/EBMT Mantle Cell Lymphoma guidance	2021 (Munshi et al. / summarized)	Recommends autologous HCT consolidation in eligible newly diagnosed MCL (Grade A*); detailed statements on TP53 mutation, CAR‑T, and allo options in relapsed disease.
NCCN Systemic Light Chain Amyloidosis	v1.2026 (June 11, 2025)	All newly diagnosed SLCA with organ involvement should be assessed for autologous HCT eligibility; preferred only for carefully selected patients with single vital organ involvement and <10% marrow plasma cells.
NCCN Older Adult Oncology / HCT-CI	2025	Recommends using HCT‑CI to assess comorbidity in older adults being evaluated for HCT; highlights AYA survivorship and GVHD risks.
CMS Medicare determinations referenced	NCD revision effective 2016‑01‑27	Policy references National Coverage Determination STEM CELL Transplantation (formerly 110.8.1) and numerous LCDs; instructs review of current Medicare policy for applicability.

Literature and guideline summaries: disease-specific randomized trials, meta-analyses and observational series support HCT in selected populations — for example, myeloablative allogeneic HCT for subsets of ALL and AML, autologous HCT for multiple myeloma and relapsed Hodgkin lymphoma, and allogeneic HCT as standard of care for higher‑risk MDS and some myelofibrosis scenarios. Evidence varies by disease: RCTs and meta-analyses exist for some indications (AML, ALL, MM, relapsed Hodgkin lymphoma), while other indications rely on nonrandomized or observational data and consensus guidance. The literature supports distinctions between autologous and allogeneic approaches based on disease biology, donor availability, and trade-offs in relapse risk versus treatment‑related morbidity/mortality.

Medicare Determinations

Determination Type	Name	Effective Date	Number
NCD	STEM CELL Transplantation (Formerly 110.8.1)	2016-01-27	Formerly 110.8.1
NCD	STEM CELL Transplantation (Formerly 110.8.1)	2016-01-27
LCD	Numerous (various contractors)	(various)

Medicare and administrative reminder: review current Medicare NCDs/LCDs (e.g., NCD 'STEM CELL Transplantation' formerly 110.8.1, effective 2016-01-27) and the patient’s benefit plan document before authorizing or billing; adherence to Medicare and contractor coverage rules may affect reimbursement and prior authorization requirements.

Definitions

Term	Definition
Autologous transplant	Transplant using a person's own hematopoietic stem cells harvested prior to high‑dose therapy and reinfused after treatment.
Allogeneic transplant	Transplant using hematopoietic stem cells from a donor (related or unrelated) with ideally matched HLA.
Myeloablative	Transplant using very high doses of chemotherapy or radiation prior to transplantation (high‑intensity conditioning).
Non-myeloablative	Reduced intensity transplant using lower doses to minimize upfront toxicity while retaining graft versus tumor effect (also called reduced‑intensity conditioning).
HCT-CI	Hematopoietic Cell Transplantation‑Specific Comorbidity Index — recommended assessment tool to evaluate comorbidities prior to HCT.
GVHD	Graft‑versus‑host disease — immune complication of allogeneic transplant that contributes to non‑relapse mortality.
CR / PR / PD	CR = complete response/remission; PR = partial remission/response; PD = progressive disease — used to describe disease status at time of transplant decisions.
ASCT	Autologous stem cell transplant — high‑dose therapy with autologous hematopoietic stem cell rescue (HDT/ASCR).
HSCT / HCT	Hematopoietic stem cell transplantation / hematopoietic cell transplantation (includes autologous and allogeneic approaches).
Deauville score	PET response scoring system; Deauville ≤3 typically indicates metabolic complete response and is used (pediatric CHL) to guide proceeding to HDT/ASCR.
C/N/S coding shorthand	Letters used in document to indicate coverage designation: C = Covered (standard/clinical evidence); N = Not generally recommended / Not covered; S = Selected/conditional or standard in some contexts (document uses C/N/S coding in tables).
POD24	Progression of disease within 24 months — used specifically in follicular lymphoma guidance to identify high‑risk relapsed patients (POD24) considered for autologous transplant in select scenarios.
ASCT (alternate label)	Autologous stem cell transplant (alternate shorthand seen in document — ASCT/HDT/ASCR overlap).
NCD / LCD	NCD = National Coverage Determination; LCD = Local Coverage Determination (Medicare coverage terms referenced in policy Appendix and Medicare section).
HCT eligibility thresholds	Examples of physiologic thresholds that may contraindicate HCT: EF <35%; bilirubin >2.0 mg/dL; transaminases >2x normal; CrCl <50 mL/min (relative for many autologous transplants); DLCO <50% predicted; Karnofsky <60% or ECOG >2.

Clinical Thresholds & Contraindications

Coverage Determinations by Disease & Remission Status (matrix)

Disease / Category	CR1 / First remission	Relapse / CR2 / Sensitive relapse	Primary refractory / Resistant / Not in remission	Post‑autologous relapse / Special scenarios
Burkitt lymphoma (BL)	CR1 = N	First or greater relapse, sensitive = C	First or greater relapse, resistant = C (table notes some variability)	Relapse after autologous transplant = C
Lymphoblastic B‑cell NHL (non‑Burkitt)	CR1, standard risk = N	CR2 = S (variable)	CR3+ / Not in remission = C or variable; some fragments show C for CR3+ and not in remission
T‑cell NHL	CR1, standard risk = N	CR2 = S / C depending on subtype	CR3+ = C	Not in remission = C or N depending on context
Cutaneous T‑cell lymphoma (CTCL) / MF / SS	Autologous HCT = N for mycosis fungoides and Sezary syndrome (autologous not medically necessary)	Relapse = Allogeneic HCT may be considered (S/C) — referral recommended for stage IIB+ refractory disease (ASTCT/USCLC guidance)	Progressive disease at time of allo‑HCT = Not recommended	Allo‑HCT considered for stage IIB+ refractory/after ≥2 lines; ideal disease status CR or at least PR at transplant.
Diffuse Large B‑cell Lymphoma (DLBCL) / HGBCL	CR1 (PET negative) = Autologous HCT = N (panel does not recommend consolidation)	Primary refractory, sensitive = Autologous HCT = S; Allogeneic HCT = S	Primary refractory, resistant = Allogeneic HCT = C; Autologous = N	Secondary CNS involvement achieving CR = autologous HCT may be considered (C) for selected patients; PCNSL in CR1 = autologous HCT consolidation recommended (A)
Hodgkin lymphoma	CR1 (PET negative) = Allogeneic N; Autologous N	First relapse, sensitive = Allogeneic S or N in fragments; Autologous S	Primary refractory, sensitive = Allogeneic C; Autologous S	Relapse after autologous transplant = Allogeneic S; Autologous N
Multiple Myeloma (MM)	Active (symptomatic) MM = Autologous HCT medically necessary (preferred consolidation in transplant‑eligible patients)	Sensitive relapse / first relapse = Autologous HCT recommended as salvage (ASTCT Grade A)	Refractory = Allogeneic HCT generally not recommended outside trials; autologous may be used in refractory settings (per ASTCT categories)	Second autologous HCT considered medically necessary for progressive disease after prior autologous HSCT under specific criteria (remission intervals per thresholds).
Acute Myeloid Leukemia (AML)	CR1: Allogeneic HCT = recommended for adverse/intermediate risk; favorable‑risk = generally N (exceptions)	CR2+ / second or subsequent remission = Allogeneic HCT = recommended (C/S designations in tables)	Not in remission = Allogeneic HCT = C in many high‑risk contexts; autologous indicated only when allo not available or appropriate (per policy)	Therapy‑related / secondary AML: allo‑HCT recommended in CR1 except select favorable karyotypes.
Myelodysplastic Syndromes (MDS) / CMML / JMML	Higher‑risk MDS (IPSS‑R Intermediate/High/Very High) = Allogeneic HCT recommended for eligible patients	Relapsed / progressive disease = Allogeneic HCT considered when eligible; CMML per MDS guidance	Autologous HCT generally experimental/unproven for CMML/JMML in many settings	Second allo‑HCT may be considered if relapse >6 months after first allo and in remission at time of second transplant.
Primary CNS Lymphoma (PCNSL)	CR1 (consolidation) = Autologous HCT recommended as consolidation for eligible patients (ASTCT/ASBMT statement, NCCN supports thiotepa‑containing regimens)	Relapse, sensitive = High‑dose chemotherapy with stem cell rescue may be considered (category 2B) only if CR/PR to reinduction; retreatment allowed if prior response and time to relapse ≥1 year	Relapse, refractory = Other options include RT or alternate systemic therapy; stem cell rescue not recommended without response to reinduction.
Legend / Notes	C = Covered / standard of care; N = Not generally recommended / Not covered; S = Selected/conditional; R = Review/rare. Many table entries are fragmented and vary by age group and guideline source — see policy text for detail where inconsistent.

Professional Society & Panel Recommendations (selected statements)

Key consensus recommendations from professional societies: ASTCT/ASBMT and NCCN guidance inform high-impact recommendations — examples include: autologous HCT preferred for transplant‑eligible multiple myeloma (ASTCT/NCCN, Grade A statements); allogeneic HCT recommended for intermediate/high‑risk MDS and for certain high‑risk or refractory leukemias; and graded panel recommendations for lymphoma subtypes (ASBMT/ASTCT guidance with panel grades A/B/C). For DLBCL/HGBCL, ASBMT guidance gives Grade A evidence against routine autologous HCT consolidation after first‑line CR, and supports autologous HCT for primary CNS lymphoma in CR1 (Grade A) with thiotepa‑containing conditioning (Grade B). For MF/SS (mycosis fungoides/Sézary), ASTCT/USCLC guidance recommends referral for allo‑HCT in specified advanced disease scenarios (panel Grade C). Sources: NCCN, ASTCT/ASBMT, ASBMT consensus documents and specialty society recommendations cited in the policy.

Operational Notes & FAQs (quick reference)

Operational provider reminders: refer all patients who meet eligibility criteria to an HCT center for evaluation; document eligibility assessments (HCT‑CI, organ function, performance status, cytogenetic/molecular risk and remission status). For younger patients where tandem or repeat HCT may be considered, collect hematopoietic stem cells sufficient for at least two transplants. For pediatric HDT/ASCR in relapsed/refractory classical Hodgkin lymphoma, document metabolic CR on FDG‑PET (Deauville score ≤3) after re‑induction before proceeding to HDT/ASCR. Prior authorization is typically required where coverage determinations are conditional on disease state, remission status, prior therapies and listed coverage criteria; remember to review Medicare determinations and to use active CPT/HCPCS codes when reporting services.

Revision History

2024-01-15focused_review

Focused review transferred Primary Central Nervous System Lymphoma (PCNSL) content into this policy (content removed from CP 0534 and added here).

2024-08-15annual_review

Annual review noted; no clinical policy statement changes.

2025-12-15annual_reviewLatest

OpenPayer

Hematopoietic Stem Cell Transplantation (HSCT) for hematologic malignancies

Coverage Summary

Medical-Necessity Criteria (by indication)

Coding

Provider Actions & Operational Requirements

Background, Guideline & Evidence Summary

Medicare Determinations

Definitions

Clinical Thresholds & Contraindications

Coverage Determinations by Disease & Remission Status (matrix)

Professional Society & Panel Recommendations (selected statements)

Operational Notes & FAQs (quick reference)

Revision History