ModifiedPremera BluecrossPolicy 8.01.28

Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

Defines medical necessity and investigational indications for autologous, tandem autologous, and allogeneic hematopoietic cell transplantation (HCT) to treat central nervous system embryonal tumors and ependymoma; intended for clinician reviewers and payers.

Policy Summary

PayerPremera Bluecross

PolicyHematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

Policy CodePolicy 8.01.28

Change TypeCoding addition and editorial/terminology updates

Effective DateApr 1, 2026

Next Review Date

Key ActionSubmit prior authorization with medical record documentation demonstrating diagnosis, severity, prior treatments, and applicable CPT/HCPCS codes (including newly added CPT 38230).

SourceLink

POLICY UPDATE CHANGES

Policy updated with effective date Apr. 1, 2026 and last revised Mar. 9, 2026.

Added CPT code 38230 as it aligns with policy criteria.

Changed wording from 'patient' to 'individual' throughout the policy for standardization.

Changed 'hematopoietic stem cell transplantation' to 'hematopoietic cell transplantation' per NCCN terminology change.

04/01/26most recent approval date

CPT 38230 addedCoding update

NCCN v.3.2025Guideline cited

<30%

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

long-term control rate

≤3 yrsage threshold

Coverage Criteria

Medically Necessary Indications

Covered when ALL of the following are met:

Autologous HCT — previously untreated embryonal tumors consolidation: Autologous hematopoietic cell transplantation may be considered medically necessary as consolidation therapy for previously untreated embryonal tumors of the central nervous system that show partial or complete response to induction chemotherapy, or stable disease after induction therapy.age ≤3 years for consideration in certain protocols

See age considerations for application; intended for high-risk groups; documentation required

Autologous HCT — recurrent disease: Autologous hematopoietic cell transplantation may be considered medically necessary to treat recurrent embryonal tumors of the central nervous system.none

Outcomes vary by tumor type; long-term control limited

Investigational / Not Medically Necessary Indications

Not covered / Investigational when ANY of the following apply:

Tandem autologous HCT: Tandem autologous hematopoietic cell transplant is investigational to treat embryonal tumors of the central nervous system.none

Evidence insufficient to demonstrate improved net health outcome

Allogeneic HCT for embryonal tumors: Allogeneic hematopoietic cell transplantation is investigational to treat embryonal tumors of the central nervous system.none

Limited evidence (case reports); insufficient to demonstrate benefit

HCT for ependymoma: Autologous, tandem autologous, and allogeneic hematopoietic cell transplant are investigational to treat ependymoma.none

Available case series do not show higher survival compared with standard therapies

Use of autologous HCT as consolidation therapy in individuals with average-risk medulloblastoma (defined in this policy as those older than 3 years, without metastatic disease, and with total or near-total resection) is not supported because studies have not shown a survival benefit compared with conventional therapies. The policy therefore does not endorse autologous HCT for that subgroup outside of clinical trials.

The American Society for Transplantation and Cellular Therapy (formerly the American Society for Blood and Marrow Transplantation) consensus guidance (2015, updated 2020) does not address use of HCT for ependymoma. While the Society provides recommendations for other pediatric CNS tumors, ependymoma is not specifically included in those recommendations and no guidance is provided to support routine use of autologous or allogeneic HCT for this diagnosis.

This medical policy is not applicable to Medicare Advantage plans. Coverage determinations for Medicare Advantage members are governed by their specific member benefit plan; providers and members should consult the benefit booklet or contact customer service for plan-specific limits.

Both tandem autologous HCT and allogeneic HCT for CNS embryonal tumors are considered investigational / not medically necessary in this policy. The available evidence comprises small prospective and retrospective single-arm studies for tandem autologous HCT and limited case reports for allogeneic HCT; these data are insufficient to demonstrate an improvement in net health outcomes such as overall survival or durable disease control. For ependymoma, small case series do not show higher survival with HCT compared with standard therapies, supporting the investigational designation.

Coding

CPT codesCPT

38230	Bone marrow harvesting for transplantation; allogeneic.
38232	Bone marrow harvesting for transplantation; autologous.
38240	Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor.
38241	Hematopoietic progenitor cell (HPC); autologous transplantation.

HCPCS codesHCPCS

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.

Covered CPT Codes (policy-aligned additions)CPT

38230

CPT code 38230 (added to policy in 2026)

Referenced CPT CodesCPT

38230

CPT code 38230 added to align with policy criteria

Provider Actions & Administrative Requirements

Prior Authorization

Prior Authorization & Verification

Prior authorization is required for hematopoietic cell transplantation (HCT) procedures and associated services when the member’s benefit plan requires it. Authorization requirements vary by member plan; providers must verify benefits and obtain prior authorization when applicable before scheduling HCT services.

Submit clinical documentation demonstrating that the medical necessity criteria are met (see Documentation Requirements).
Include relevant CPT/HCPCS codes (e.g., CPT 38230, 38232, 38240, 38241; HCPCS S2150) on authorization requests as applicable.
If prior authorization is not obtained when required by the member’s plan, services may be denied.

Documentation Required

Documentation Requirements and Risk of Denial

The medical record submitted for prior authorization and claims review must document that the coverage criteria are met. Insufficient or missing documentation may result in denial of the request or claim.

Background

Central nervous system embryonal tumors (including medulloblastoma) are predominantly pediatric neuroepithelial malignancies for which intensive multimodality therapy is standard. High-dose chemotherapy can be marrow-toxic, and hematopoietic cell transplantation (HCT) — using either the individual's harvested cells (autologous HCT) or donor cells (allogeneic HCT) — is used to restore marrow function after marrow-ablative regimens or, in the case of allogeneic transplant, to attempt graft-versus-tumor effects.

Autologous HCT is typically considered as consolidation therapy when disease has responded to induction chemotherapy or is in remission; in recurrent disease it may be used with curative or salvage intent. Evidence for tandem autologous HCT is limited to small single-arm series that suggest similar short-term survival to single autologous HCT but do not establish improved long-term disease control. Allogeneic HCT evidence is restricted to case reports and is inadequate to demonstrate benefit.

Because autologous HCT has not shown benefit in certain lower-risk subgroups (for example, average-risk medulloblastoma — individuals older than 3 years, nonmetastatic, with total or near-total resection), and because long-term disease control after HCT for recurrent embryonal tumors remains limited, the policy limits medically necessary indications to specific high-risk or recurrent scenarios and designates tandem and allogeneic approaches as investigational.

Definitions

Autologous hematopoietic cell transplantation

DefinitionAutologous hematopoietic cell transplantation (autologous HCT) — transplantation using the individual's own hematopoietic stem cells harvested prior to high-dose chemotherapy and later infused to restore bone marrow and immune function.

Source harvest sitesStem cells may be harvested from bone marrow or peripheral blood for autologous HCT.

Immunologic compatibilityImmunologic compatibility is not an issue because the individual's own cells are used.

Typical indicationUsed to restore marrow function after marrow-toxic high-dose chemotherapy, often as consolidation when disease is in remission.

Procedure descriptionHematopoietic stem cells are intravenously infused to repopulate bone marrow and reconstitute immune function after intensive therapy.

Policy Summary

PayerPremera Bluecross

PolicyHematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

Policy CodePolicy 8.01.28

Change TypeCoding addition and editorial/terminology updates

Effective DateApr 1, 2026

Next Review Date

Key ActionSubmit prior authorization with medical record documentation demonstrating diagnosis, severity, prior treatments, and applicable CPT/HCPCS codes (including newly added CPT 38230).

SourceLink

On This Page

Required documentation should include: diagnosis/condition, history and physical exam detailing severity, prior treatments, and evidence that policy coverage criteria and age/risk stratification (when applicable) are met.
Failure to include requested records or to respond to medical record requests in a timely manner can lead to adverse benefit determinations.

Step Therapy

Step Considerations

Autologous hematopoietic cell transplantation is used as consolidation therapy in specific populations (see Coverage Criteria). Age and risk stratification guide appropriateness—for example, consolidation HCT considerations in previously untreated embryonal CNS tumors apply primarily to children age 3 or younger and to defined high-risk groups.

Confirm patient meets the policy’s clinical criteria and age/risk definitions before requesting authorization.
Clinical rationale should reference risk group (average vs high risk) and prior response to induction therapy where relevant.

Step Therapy

Treatment Sequence & Guideline Context

Guideline and sequence context (NCCN, ASTCT/ASBMT) supports use of HCT in certain recurrent or high‑risk settings; include prior lines of therapy and guideline rationale in authorization requests.

For recurrent localized medulloblastoma, high-dose chemotherapy with autologous HCT is a NCCN category 2A option—document prior resection and prior therapies.
Reference society guideline recommendations (ASTCT/ASBMT updates) as applicable to the indication when submitting clinical justification.

Note

Provider Action Highlights

Provider action notes and administrative reminders: verify benefit limits and plan exclusions that may preclude coverage; acknowledge coding updates in 2026.

Verify member benefits and any applicable plan limitations or exclusions by consulting the member benefit booklet or contacting customer service.
Use updated coding — include CPT 38230 on authorization/claim submissions where applicable per the 2026 policy update.
Be aware this medical policy does not apply to Medicare Advantage; check Medicare-specific guidance where relevant.

Allogeneic hematopoietic cell transplantation (allo-HCT)

DefinitionAllogeneic hematopoietic cell transplantation (allo-HCT) — transplantation using hematopoietic stem cells obtained from a donor (bone marrow, peripheral blood, or umbilical cord blood) and infused into the recipient.

HLA compatibilityImmunologic compatibility between donor and recipient is critical and is established by HLA typing (HLA-A, -B, -DR loci).

Donor sourcesDonor stem cells may come from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates.

Clinical considerationsAllo-HCT carries risks related to immune incompatibility (e.g., graft-versus-host disease) and requires careful donor-recipient matching.

HCT regulatory context

Regulatory authorityThe U.S. Food and Drug Administration regulates human cells and tissues intended for implantation, transplantation, or infusion under 21 CFR parts 1270 and 1271.

ScopeHematopoietic stem cells used in HCT are included within these FDA regulations.

Regulatory centerRegulation is through the FDA Center for Biologics Evaluation and Research (CBER).

Autologous HCT (alternate reference)

Alternate-definitionAutologous HCT — hematopoietic cell transplantation using the individual's own harvested hematopoietic stem cells (autologous stem-cell rescue or transplant) to restore marrow after marrow-toxic therapy.

Harvest and infusionCells can be harvested from the individual prior to high-dose chemotherapy and later infused intravenously to reconstitute marrow and immune function.

Compatibility noteBecause cells are autologous, immunologic compatibility between donor and recipient is not a concern.

Clinical roleOften employed as consolidation therapy when disease shows response or stable disease after induction chemotherapy.