Fidelis Care Pediatric Autologous HSCT Prior Auth

Medical Necessity — Coverage Criteria (Pediatric Autologous HSCT)

Medulloblastoma

Covered when ALL of the following are met

Medulloblastoma criteria: 1. Age < 18; 2. High-risk disease; 3. Performance status - one or more of: Lansky score ≥ 50%, Karnofsky score ≥ 70%, or ECOG grade 0-2; 4. No active infection, or infection controlled; 5. No drug or alcohol misuse by history or drug and alcohol free period ≥ 4 weeks; 6. Patient or caregiver understanding of procedural risk and post procedure compliance and follow-up; 7. Patient has adequate social or family support

Hodgkin lymphoma

Covered when ALL of the following are met

Hodgkin lymphoma criteria: 1. Age < 18; 2. Therapeutic response - one of: induction failure, partial remission, or relapsed disease; 3. Performance status - one or more of: Lansky score ≥ 50%, Karnofsky score ≥ 70%, or ECOG grade 0-2; 4. No active infection, or infection controlled; 5. No drug or alcohol misuse by history or drug and alcohol free period ≥ 4 weeks; 6. Patient or caregiver understanding of procedural risk and post procedure compliance and follow-up; 7. Patient has adequate social or family support

Germ cell tumors

Covered when ALL of the following are met

Germ cell tumor criteria: 1. Age < 18; 2. Diagnosis confirmed by biopsy; 3. Therapeutic response - one of: induction failure or relapsed disease; 4. Performance status - one or more of: Lansky score ≥ 50%, Karnofsky score ≥ 70%, or ECOG grade 0-2; 5. No active infection, or infection controlled; 6. No drug or alcohol misuse by history or drug and alcohol free period ≥ 4 weeks; 7. Patient or caregiver understanding of procedural risk and post procedure compliance and follow-up; 8. Patient has adequate social or family support

Ewing family of tumors

Covered when ALL of the following are met

Ewing tumor criteria: 1. Age < 18; 2. Disease type - one of: high-risk disease or relapsed disease; 3. Performance status - one or more of: Lansky score ≥ 50%, Karnofsky score ≥ 70%, or ECOG grade 0-2; 4. No active infection, or infection controlled; 5. No drug or alcohol misuse by history or drug and alcohol free period ≥ 4 weeks; 6. Patient or caregiver understanding of procedural risk and post procedure compliance and follow-up; 7. Patient has adequate social or family support

Neuroblastoma

Covered when ALL of the following are met

Neuroblastoma criteria: 1. Age < 18; 2. Disease type - one of: high-risk disease or relapsed disease; 3. Performance status - one or more of: Lansky score ≥ 50%, Karnofsky score ≥ 70%, or ECOG grade 0-2; 4. No active infection, or infection controlled; 5. No drug or alcohol misuse by history or drug and alcohol free period ≥ 4 weeks; 6. Patient or caregiver understanding of procedural risk and post procedure compliance and follow-up; 7. Patient has adequate social or family support

Transplantation may be denied or deferred when there is evidence of active uncontrolled infection, significant irreversible organ dysfunction (identified during pre‑transplant evaluation of hepatic, pulmonary, cardiac or renal function), or ongoing substance abuse without documentation of counseling and a period of abstinence. Pre‑transplant screening explicitly requires control of active infections and assessment of organ reserve because these factors increase post‑transplant morbidity and mortality. A history of noncompliance or chemical dependency is considered predictive of poorer postoperative outcomes and should be addressed prior to authorization.

Coverage for neuroblastoma is limited to autologous hematopoietic stem cell transplantation when the diagnosis is coded as malignant neoplasm of the adrenal gland (ICD‑10 C74.90–C74.92). Requests for transplant for neuroblastoma at other primary sites do not meet the specific autologous transplant limitation described in this policy.

Patients with an irreversible poor performance status—defined in this policy as Lansky <50 or Karnofsky <70 or ECOG >2—are generally considered to have poor prognosis and are not appropriate candidates for autologous transplant. Performance status must meet the policy thresholds (Lansky ≥50 or Karnofsky ≥70 or ECOG 0–2) to be considered medically eligible.

Relevant Procedure and Diagnosis Codes

CPT codes that support coverage criteriaCPTCovered

38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous.
38232	Bone marrow harvesting for transplantation; autologous.
38241	Hematopoietic progenitor cell (HPC); autologous transplantation

mixed

No codes listed

HCPCS codes that support coverage criteriaHCPCSCovered

S2150

Bone marrow or blood-derived peripheral 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

ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered

C40 - C41.9	Malignant neoplasm of bone and articular cartilage or limbs [specified as Ewing's sarcoma].
C56.1 - C56.9	Malignant neoplasm of ovary (specified as germ cell).
C62 - C62.92	Malignant neoplasm of testis.
C71.6	Malignant neoplasm of cerebellum.
C74.90 - C74.92	Malignant neoplasm of adrenal gland (neuroblastoma) [autologous only].
C81 - C81.99	Hodgkin Lymphoma and subtypes

ICD-10 Diagnosis Codes that Support Coverage CriteriaICD-10Covered

C40 - C41.9	Malignant neoplasm of bone and articular cartilage or limbs [specified as Ewing's sarcoma]
C56.1- C56.9	Malignant neoplasm of ovary (specified as germ cell)
C62-C62.92	Malignant neoplasm of testis
C71.6	Malignant neoplasm of cerebellum
C74.90-C74.92	Malignant neoplasm of adrenal gland (neuroblastoma) [autologous only]
C81- C81.99	Hodgkin Lymphoma and subtypes

Performance status thresholds

Lansky performance statusScore ≥ 50% required (acceptable alternative to Karnofsky or ECOG)

Karnofsky performance statusScore ≥ 70% required (acceptable alternative to Lansky or ECOG)

ECOG performance statusGrade 0–2 required (acceptable alternative to Lansky or Karnofsky)

Provider Requirements, Prior Authorization, and Pre-Transplant Evaluation

Prior Authorization

Prior Authorization Required and Documentation

Prior authorization is required. Requests must document that the patient meets the disease‑specific medical necessity criteria in this policy (e.g., age < 18, disease type and status such as high‑risk or relapsed disease, required performance status, absence or control of active infection, substance‑free period, informed consent/compliance, and adequate social/family support). Provide relevant clinical records (diagnosis, staging/biopsy results, performance scores, infectious disease testing, organ function testing, and documentation of patient/caregiver informed consent and social support).

Prior authorization required prior to scheduling transplant
Include diagnostic confirmation and staging/biopsy when applicable
Include performance status (Lansky, Karnofsky, or ECOG)
Include documentation that infections are absent or controlled and infectious disease screening results
Include organ function testing (hepatic, pulmonary, cardiac, renal) and relevant test results
Document substance‑free period or history and counseling if prior dependence
Document patient/caregiver understanding of risks, consent, and post‑procedure follow‑up plans
Document adequate social or family support

Background and Scope

Autologous hematopoietic stem cell transplantation uses the patient’s own bone marrow or peripheral blood–derived hematopoietic progenitor cells and is an established treatment option for select high‑risk or relapsed pediatric malignancies. Because transplantation carries substantial risk of complications—especially infectious and organ‑system toxicities—a comprehensive pre‑transplant evaluation is required to assess hepatic, pulmonary, cardiac, and renal function, screen for infectious diseases (including hepatitis, CMV, and HIV), and identify dental or other infection sources. The evaluation helps determine whether a patient’s medical status and social supports are adequate to proceed and to predict the likelihood of a successful outcome.

Definitions — Tumor Types and Terms

Medulloblastoma

DefinitionMost common pediatric brain tumor; diagnosis confirmed by pathology after tumor resection

Typical presentation and ageOften presents with headache, lethargy, vomiting, ataxia, visual changes; ~90% diagnosed before age 10

Transplant indicationAutologous stem cell transplant appropriate for high-risk disease (incomplete resection, positive CSF cytology, MRI evidence of seeding, or extraneural metastases)

Hodgkin lymphoma

DefinitionCancer of the immune system distinguished by presence of Reed–Sternberg cells

EpidemiologyTypically affects adolescents and young adults (commonly ages 15–30) and older adults

OpenPayer

Autologous Hematopoietic Stem Cell Transplant (Pediatric)

Medical Necessity — Coverage Criteria (Pediatric Autologous HSCT)

Relevant Procedure and Diagnosis Codes

Provider Requirements, Prior Authorization, and Pre-Transplant Evaluation

Background and Scope

Definitions — Tumor Types and Terms