CurrentPremera BluecrossPolicy N/A

Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer — Coverage Criteria

This policy governs coverage for autologous and allogeneic hematopoietic cell transplantation (HCT) when used to treat advanced-stage epithelial ovarian cancer and informs providers and payers about the medical necessity stance.

Policy Summary

PayerPremera Bluecross

PolicyHematopoietic Cell Transplantation for Epithelial Ovarian Cancer — Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual reviewno material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements before submitting claims for HCT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Investigationalcoverage stance for HCT in advanced epithelial ovarian cancer

0 trialsrandomized trial evidence for HCT benefit

CPT/HCPCS listedbilling codes included in policy

Unchangedpolicy statement stability

Coverage Criteria for Hematopoietic Cell Transplantation

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Billing and Coding

Covered CPT Codes (listed)CPT

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 Codes (listed)HCPCS

S2142

Cord blood-derived stem-cell transplantation, allogeneic

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

Coding history notes (added/removed codes over time)mixed

38204	CPT code 38204 (removed from policy as noted in history entries)
38220	CPT code 38220 (removed; does not apply to this policy)
38221	CPT code 38221 (removed; does not apply to this policy)
38232	CPT code 38232 (added 01/24/12 per history)
38242	CPT code 38242 (removed; did not match criteria)
S2140	HCPCS S2140 (removed 10/01/22)

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required for HCT Procedures

Prior authorization is required for hematopoietic cell transplant (HCT) procedures when billed with the CPT and HCPCS codes listed in this policy. Submit a prior authorization request before scheduling HCT to confirm medical necessity and benefit eligibility.

Affected codes: CPT 38230, 38232, 38240, 38241; HCPCS S2142, S2150
Obtain prior authorization prior to service to avoid claim denials

Note

Verify Prior Authorization and Benefits

Verify member-specific benefits and prior authorization requirements before providing services. Coverage for HCT is subject to the member’s plan limits and may be denied if not consistent with policy criteria.

Check the member benefit booklet or contact customer service for coverage limits and exclusions
Confirmation of prior authorization does not guarantee payment — claims are subject to plan terms

Step Therapy

Step Therapy Context

Standard treatment for advanced epithelial ovarian cancer is cytoreductive surgery with platinum- and taxane-based chemotherapy. Hematopoietic cell transplantation (HCT) is considered investigational for this indication and is not established as standard therapy.

Standard regimen: paclitaxel plus a platinum analogue (e.g., cisplatin)
HCT is investigational for advanced-stage epithelial ovarian cancer and not supported by randomized trial evidence

Documentation Required

Benefit Application and Documentation Considerations

State mandates or participation in NIH-approved clinical trial coverage programs may supersede this policy. Document any applicable trial participation or state-specific mandate when requesting authorization.

If the member is enrolled in an NIH-approved clinical trial, see plan-specific trial coverage provisions
Include trial documentation or state-mandate references with the authorization request when applicable

Denial Risk

Denial Risk for HCT in Epithelial Ovarian Cancer

Requests for autologous or allogeneic HCT to treat advanced-stage epithelial ovarian cancer are subject to denial under this policy, as HCT is considered investigational for this condition.

Denial risk: autologous and allogeneic HCT for advanced epithelial ovarian cancer
Denials may be issued if submitted indications do not meet investigational exceptions (e.g., applicable trial or mandate)

Note

Member Benefit Verification Required

Always verify member benefits prior to authorization. Coverage is determined by the member’s plan and may vary; contact customer service or consult the member benefit booklet for definitive coverage information.

Benefit verification required for each request
Coverage subject to plan limits and exclusions

Background

Hematopoietic cell transplantation (HCT) is a procedure in which hematopoietic stem cells are infused to restore bone marrow function after marrow‑ablative or marrow‑toxic therapy. HCT may be autologous (stem cells harvested from and returned to the same patient) or allogeneic (stem cells obtained from a donor). HCT is an established therapy for certain hematologic malignancies because it permits delivery of high‑dose chemotherapy with subsequent hematopoietic rescue, but for most adult solid tumors—including epithelial ovarian cancer—HCT remains experimental. The key clinical outcomes evaluated include overall survival, disease‑specific survival, remission status, and treatment‑related morbidity and mortality, and available evidence has not shown that HCT improves these outcomes in epithelial ovarian cancer compared with conventional therapy.

Definitions and Guideline References

Autologous HCT — definition entry

DefinitionAutologous hematopoietic cell transplantation (HCT): hematopoietic stem cells harvested from the patient prior to high‑dose, marrow‑toxic chemotherapy and reinfused to restore bone marrow function.

Source materialStem cells may be harvested from the individual before they receive high‑dose chemotherapy (autologous).

Common harvest sitesBone marrow or peripheral blood (patient‑derived).

Allogeneic HCT — definition entry

DefinitionAllogeneic hematopoietic cell transplantation (HCT): hematopoietic stem cells obtained from a donor (bone marrow, peripheral blood, or umbilical cord blood/placenta) and infused into the patient.

Clinical considerationsAllogeneic sources include bone marrow, peripheral blood, or cord blood; cord blood is antigenically naive and associated with lower incidence of rejection or graft‑versus‑host disease.

NCCN guidelines — reference

GuidelineNCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, Version 3.2025.

Related guidelineNCCN Clinical Practice Guidelines in Oncology: Hematopoietic Cell Transplantation (HCT), Version 3.2025.

AccessGuidelines available via NCCN website (references list includes URLs and access date).

CMS NCD 110.23 — reference

NCD titleCenters for Medicare & Medicaid Services National Coverage Determination (NCD) for Stem Cell Transplantation, NCD 110.23 (formerly 110.8.1).

Year and accessListed in references as 2024 NCD; CMS NCD details available on the Medicare Coverage Database (reference includes URL and access date).

RelevanceReferenced for coverage considerations related to stem cell transplantation in the policy.