CurrentColorado Rocky Mountain Health PlansPolicy CS127.P

Umbilical Cord Blood Harvesting and Storage for Future Use – Community Plan Medical Policyopen_in_new

Policy governs coverage stance for prophylactic collection and private storage of umbilical cord blood for future unspecified autologous or allogeneic transplantation; excludes certain state-specific applicability. Provides supporting evidence, clinical guidance references, and applicable procedure codes for reference.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUmbilical Cord Blood Harvesting and Storage for Future Use – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS127.P

Change TypeRevised coverage rationale; application and template updates

Effective DateOct 1, 2025

Next Review Date

Key ActionFor coverage of umbilical cord blood stem cell transplantation, refer to the Optum Clinical Guideline titled Hematopoietic Stem Cell Transplantation.

SourceLink

POLICY UPDATE CHANGES

10/01/2025 Coverage Rationale language updated to specify 'prophylactic collection and storage ... is unproven and not medically necessary for an individual who is currently healthy but desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation due to insufficient evidence of efficacy.'

11/01/2025 Application updated to indicate policy does not apply to Nebraska and North Carolina (state-specific versions exist).

04/01/2026 Template update removed content/language pertaining to the state of Louisiana.

1Primary Coverage Position (Not Medically Necessary)

11States with separate policies (excluded)

Coverage Summary

Scope: Policy governs coverage stance for prophylactic collection and private storage of umbilical cord blood for future unspecified autologous or allogeneic transplantation; excludes certain state-specific applicability. Provides supporting evidence, clinical guidance references, and applicable procedure codes for reference.

Overview: This policy addresses harvesting and cryopreservation of umbilical cord and placental blood stem cells for potential future use. Effective date: October 1, 2025. Last review date: April 1, 2026.

Key Facts: Umbilical Cord Blood Harvesting and Storage

Primary Coverage PositionNot medically necessary (prophylactic collection and storage is unproven due to insufficient evidence of efficacy)

States with separate policies (excluded)11 states (Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee)

Policy NumberCS127.P

StatusCURRENT

Effective DateOctober 1, 2025

Last ReviewApril 1, 2026

Coverage Rationale / Medically Necessary Determination

Umbilical cord blood harvesting and storage is considered:

Prophylactic collection and storage of umbilical cord blood for an individual who is currently healthy but desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation is unproven and not medically necessary due to insufficient evidence of efficacy.

Exceptions / When banking may be considered: Directed cord blood banking (family member banking) is recommended when there is a known sibling with a disease that may be successfully treated with an allogeneic transplant (per professional society guidance).

Policy references clinical guidelines (ACOG, ASTCT/ASBMT) that encourage directed banking when a family member has a condition treatable by cord blood transplant; however this policy's coverage statement addresses prophylactic private banking as not medically necessary.

Prophylactic collection and storage: Collection and private storage of cord blood from a healthy individual for unspecified future use — storing a newborn’s cord blood 'as insurance' for hypothetical future, unspecified autologous or allogeneic transplantation.

Directed/Family banking: Collection and storage intended for use by a known family member (for example, a sibling) with a condition that may require transplant; professional guidance supports directed banking when a family member has a treatable condition.

Not Medically Necessary / Unproven

Not covered: Prophylactic collection and storage of umbilical cord blood for an individual who is currently healthy but desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation is unproven and not medically necessary due to insufficient evidence of efficacy.

Professional guidance and evidence gap: High-quality studies evaluating storage of umbilical cord blood for hypothetical future use were not found. Major professional organizations (ACOG, AAP, AMA, ASTCT/ASBMT, RCOG) advise that routine private banking for low-risk families is not supported by current evidence, encourage public donation where possible, and recommend directed (family) banking when a family member has a disease that may be successfully treated with a cord blood transplant.

Coding

Reference Procedure Codes (listed for informational purposes only)CPT

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.
88240	Cryopreservation, freezing and storage of cells, each cell line.

HCPCS / Other codes (informational)HCPCS

S2140

Cord blood harvesting for transplantation, allogeneic.

Provider Actions / Documentation

Documentation Required

Reference Clinical Guideline for Transplant Coverage

For coverage of umbilical cord blood stem cell transplantation, refer to the Optum Clinical Guideline titled Hematopoietic Stem Cell Transplantation.

Documentation Required

State-specific Policy Applicability

Check state-specific policy versions for applicability; this Medical Policy does not apply to Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee — refer to those states' policies for coverage determinations.

Background and Evidence Summary

Background: Umbilical cord and placental blood are rich in hematopoietic stem cells used to treat conditions such as leukemia, lymphoma, myeloma, aplastic anemia, and certain immunologic and metabolic disorders. Private cord blood banks store units for potential autologous or family use; public banks accept donations for general use. Evidence is limited for routine prophylactic private banking, and searches did not identify high-quality studies supporting storage for hypothetical future use.

Evidence Summary

Clinical evidence searchNo high-quality studies found evaluating storage of umbilical cord blood for hypothetical future use.

Professional society guidance consensusACOG/AMA/ASTCT/ASBMT/RCOG: do not support routine private banking for low-risk families; encourage public donation; recommend directed/family banking when a family member has a condition treatable by cord blood transplant.

Revision History

10/01/2025revised

Coverage Rationale language updated to specify 'prophylactic collection and storage of umbilical cord blood is unproven and not medically necessary for an individual who is currently healthy but desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation due to insufficient evidence of efficacy.' Also updated Clinical Evidence and References; archived prior version CS127.O. (Material change).

11/01/2025revised

Application updated to indicate this Medical Policy does not apply to the states of Nebraska and North Carolina; refer to state-specific policy versions.

04/01/2026revisedLatest

Template update removed content/language pertaining to the state of Louisiana.