CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β -Thalassemia

Customize your policy alerts

Sign up for Community Health Plan Washington Policy MC.CP.MP.108 alerts

Get alerted when Policy MC.CP.MP.108 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 AHCT in members with sickle cell anemia or homozygous β-thalassemia, intended for Medicare health plans affiliated with Centene (affects providers requesting transplant authorization).

Policy Summary

PayerCommunity Health Plan Washington

PolicyAllogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β -Thalassemia

Policy CodePolicy MC.CP.MP.108

Change TypeClarified, Revised, Removed

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation demonstrating indication, donor availability/match status, and planned conditioning regimen.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language to Criteria I.A.1.b. regarding high risk of stroke.

Removed first-degree relative donor requirement for cord blood as the source of stem cells for homozygous β-thalassemia in Criteria I.A.2.a.i.

Removed Criteria I.A.2.d. regarding provider specializing in treating thalassemia.

Updated verbiage in Note under Criteria I.B. for clarity.

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.

CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β -Thalassemia

Customize your policy alerts

Sign up for Community Health Plan Washington Policy MC.CP.MP.108 alerts

Get alerted when Policy MC.CP.MP.108 changes without checking for updates manually.

Monitor payer policy activity

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

Policy Summary

PayerCommunity Health Plan Washington

PolicyAllogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β -Thalassemia

Policy CodePolicy MC.CP.MP.108

Change TypeClarified, Revised, Removed

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation demonstrating indication, donor availability/match status, and planned conditioning regimen.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language to Criteria I.A.1.b. regarding high risk of stroke.

Removed first-degree relative donor requirement for cord blood as the source of stem cells for homozygous β-thalassemia in Criteria I.A.2.a.i.

Removed Criteria I.A.2.d. regarding provider specializing in treating thalassemia.

Updated verbiage in Note under Criteria I.B. for clarity.

Medical Necessity and Coverage Criteria

Initial Transplant Eligibility

Covered when ALL of the following are met for Medicare health plans affiliated with Centene:

Top-level

Indication A
- Sickle cell anemia indication
  - Donor: HLA-matched, first-degree relative donor is available
    HLA-matched first-degree relative required for sickle cell per policy
  - High stroke risk or end-organ damage: History of stroke or is at high risk of stroke or end-organ damage evidenced by at least one: prior stroke, recurrent acute chest syndrome, recurrent vaso-occlusive crises, or red blood cell alloimmunization on chronic transfusion therapy
- Homozygous β-thalassemia indication
  - Donor and stem cell source: HLA-matched donor is available AND one of: cord blood is the source of stem cells, bone marrow is the source of stem cells, or peripheral blood is the source when the donor is unable or refuses bone marrow donation
  - Transfusion dependence: Member is transfusion-dependent due to thalassemia
  - Conditioning regimen: A standard, myeloablative conditioning regimen will be used
Contraindications
- Absolute contraindications list: Infections with highly virulent and/or resistant microbes that are poorly controlled pre-transplant; inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support

Note: Younger recipients generally have better outcomes following AHCT than older recipients according to cited data

Insufficient Evidence / Not Covered

Not enough evidence to support routine coverage:

Exclusion statement: Autologous hematopoietic cell transplant for sickle cell anemia and for β-thalassemia are considered to have insufficient evidence and are not covered under this policy

Autologous hematopoietic cell transplant (AHCT) for sickle cell anemia and for β-thalassemia is considered to have insufficient evidence regarding safety and efficacy to support routine coverage under this policy. The policy explicitly lists both indications—autologous HCT for sickle cell anemia and autologous HCT for β-thalassemia—as not supported by current evidence and therefore not covered as standard therapy.

AHCT is not medically necessary when any absolute contraindication is present. Examples of absolute contraindications named in the policy include: uncontrolled infections with highly virulent and/or resistant microbes that are poorly controlled before transplant, and an inability of the member to adhere to the post‑transplant regimen even with caregiver support. Presence of these conditions would normally lead to denial of transplant as medically unnecessary.

Conditioning Regimens and Transplant Approaches

Regimen component	Requirement / description
A standard, myeloablative conditioning regimen is required for transplants to treat homozygous β-thalassemia (ablative conditioning).
Myeloablative (ablative) conditioning is necessary given major risk factors for β-thalassemia such as iron-overload related organ dysfunction; control of iron overload and organ damage is a significant consideration prior to transplant.

Regimen component	Requirement / description
Reduced-intensity conditioning (nonmyeloablative/reduced-intensity) may be appropriate for sickle cell anemia to induce stable mixed chimerism and full donor erythropoiesis.
Reduced-intensity regimens can achieve stable chimerism in sickle cell patients; major transplant risk factors include age and history of cerebral events, and conditioning choice balances cure of chronic inflammation and prevention of organ damage against toxicity.

Procedure Codes and Reported Metrics

Informational procedure codesCPT | HCPCS

38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic.
38240	Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor.
S2150	Bone 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 post-transplant care in the global definition.

Reported pediatric HCT outcomes

Reported pediatric HCT success rate85–90% success rate reported for specific pediatric groups

Three‑year survival after HCTApproximately 90% three‑year survival reported (survey data)

Overall survival range in thalassemia reportsOverall survival and thalassemia‑free survival range ~65–90% across reports

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required; submit evidence meeting policy criteria

Prior authorization is required for allogeneic hematopoietic cell transplant (AHCT). Submit a prior authorization request that includes evidence demonstrating the member meets the policy's medical necessity criteria for AHCT (indication, donor availability/source, conditioning plan, and absence of absolute contraindications). Providers may reference the listed informational procedure codes when preparing the request: 38205, 38240, S2150.

Include documentation that shows the specific indication (sickle cell anemia or homozygous β-thalassemia) and that all policy criteria for that indication are met.
List donor type and HLA-match status and planned stem cell source (cord blood, bone marrow, or peripheral blood as applicable).
Provide the planned conditioning regimen (standard myeloablative for thalassemia; reduced-intensity when appropriate for sickle cell per clinical guidance) and confirmation that no absolute contraindications exist.

Step Therapy

No step therapy required — coverage based on eligibility criteria

Disease Definitions

Homozygous β‑thalassemia — definition and clinical features

Definitionβ‑thalassemia major (homozygous β‑thalassemia; Cooley’s anemia) caused by autosomal mutations in the β‑globin gene leading to deficient β‑globin synthesis

PathophysiologyIneffective erythropoiesis with toxic α‑globin aggregates destroying erythroid precursors and shortened red cell survival (hemolytic anemia)

Clinical featuresTransfusion‑dependence and iron‑overload–related organ dysfunction; risk of multi‑organ injury from chronic anemia and ineffective erythropoiesis

Sickle cell anemia — definition and clinical features

DefinitionSickle cell anemia caused by homozygous Glu6Val (β‑globin) mutation producing sickled red cells

PathophysiologyDeoxygenated hemoglobin polymerizes, producing rigid, sickled erythrocytes that occlude microvasculature and cause chronic hemolytic anemia

Clinical Background and Rationale

Sickle cell anemia and homozygous β-thalassemia are monogenic hemoglobinopathies for which allogeneic hematopoietic cell transplant (AHCT) is the only established curative option. These disorders cause chronic hemolytic anemia and progressive end‑organ injury; selection of transplant candidates balances the potential for durable cure against substantial risks such as graft rejection, graft‑versus‑host disease, infection, organ toxicities, and infertility. The policy notes that younger recipients generally have better post‑transplant outcomes than older recipients, and that disorder‑specific considerations (donor availability, stem cell source, and conditioning regimen) influence eligibility and planning for AHCT.