CurrentFidelis CarePolicy CP.FC.33

Clinical Policy: Autologous Hematopoietic Stem Cell Transplant (Pediatric)

Medical necessity criteria for autologous hematopoietic stem cell transplant in patients younger than 18 years, specifying covered disease indications, performance status, infection/substance use/social support requirements, and related coding guidance.

Policy Summary

PayerFidelis Care

PolicyClinical Policy: Autologous Hematopoietic Stem Cell Transplant (Pediatric)

Policy CodePolicy CP.FC.33

Change TypeAnnual reviews; coding and reference updates; added caregiver requirement

Effective DateFeb 1, 2021

Next Review DateN/A

Key ActionProviders must document age (<18), disease-specific indication, performance status, therapeutic response, infection control, substance-use abstinence, and patient/caregiver understanding and social support for coverage determination.

POLICY UPDATE CHANGES

Added caregiver to medical necessity criteria: Patient understanding of procedural risk and post procedure compliance and follow-up.

Updated CPT codes and revised ICD-10 diagnosis codes in annual reviews (2023-2025).

References reviewed and updated annually (most recently 01/2025).

5Covered Indications (listed diseases A-E)

3Performance scales accepted

38206,38232,38241Key CPT codes

S2150