CurrentPremera BluecrossPolicy N/A

Hematopoietic Cell Transplantation for Solid Tumors in Adults

This policy governs coverage of autologous and allogeneic hematopoietic cell transplantation (HCT) when used to treat specified solid tumors in adults for Premera Bluecross members and informs providers about investigational indications and related coding.

Policy Summary

PayerPremera Bluecross

PolicyHematopoietic Cell Transplantation for Solid Tumors in Adults

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionUse the referenced CPT and HCPCS codes when requesting prior authorization and document FDA regulatory status and plan-specific benefit application.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+Investigational tumor types

38230–38241CPT codes referenced

S2142, S2150HCPCS codes referenced

Trial-firstNESTB guidance

NCD: noncoverageCMS stance

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.

Coverage Criteria

Investigational Indications

Autologous or allogeneic hematopoietic cell transplantation is considered investigational for the following adult solid tumor malignancies:

Investigational indications list: HCT (autologous or allogeneic) is investigational for: cancer of the bile duct; cancer of the fallopian tubes; cervical cancer; colon cancer; esophageal cancer; gall bladder cancer; lung cancer (any histology); malignant melanoma; nasopharyngeal cancer; neuroendocrine tumors; pancreatic cancer; paranasal sinus cancer; prostate cancer; rectal cancer; renal cell cancer; soft tissue sarcomas; stomach cancer; thyroid tumors; tumors of the thymus; tumors of unknown primary origin; uterine cancer.

Policy states investigational for these listed adult solid tumors.

This policy does not address hematopoietic cell transplantation (HCT) for certain tumor types that are managed under separate policies or guidance. Specifically, HCT for ovarian cancer, germ cell tumors, ependymoma, and malignant glioma are covered in related, tumor-specific policies, and HCT for breast cancer is not addressed by this policy. The remainder of this policy focuses on other adult solid tumors for which HCT has been investigated, including lung cancer, malignant melanoma, gastrointestinal tract tumors (colon, rectum, pancreas, stomach, esophagus, gallbladder, bile duct), genitourinary tumors (renal cell carcinoma, prostate, cervical, uterine, fallopian tube), head and neck tumors, soft tissue sarcomas, thyroid and thymic tumors, and tumors of unknown primary origin.

The Centers for Medicare & Medicaid Services (CMS) has issued a national noncoverage decision for autologous stem cell transplantation in solid tumors: CMS states that insufficient data exist to establish definite conclusions regarding the efficacy of autologous stem cell transplantation for solid tumors (other than neuroblastoma). Under Medicare contractor rules, this national noncoverage determination may lead to denial of AuSCT for those indications.

Systematic review of available evidence, including randomized controlled trials, single-arm phase 2 studies, and small case series, does not demonstrate a consistent benefit in clinically meaningful outcomes for autologous or allogeneic HCT in the adult solid tumors reviewed. For example, trials and reviews in soft tissue sarcoma and small cell lung cancer did not show an overall survival benefit with autologous HCT, and evidence for allogeneic HCT in renal cell, colorectal, pancreatic, and nasopharyngeal cancers is limited to small case series. Overall, the evidence is insufficient to conclude improved overall survival or net health outcome for HCT in these solid tumor indications.

Guideline and expert-group positions do not support routine use of HCT for most adult solid tumors. The National Comprehensive Cancer Network (NCCN) guidelines for the tumors addressed in this policy do not list HCT as a treatment option and HCT is not included in the NCCN HCT guideline. The National Ewing Sarcoma Tumor Board recommends that autologous HCT with myeloablative conditioning for relapsed Ewing sarcoma be reserved for clinical trials. In addition, the CMS national noncoverage decision for autologous stem cell transplantation in solid tumors (except neuroblastoma) aligns with the conclusion that HCT is not established as beneficial for these indications.

Coding

Covered 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.

Covered HCPCS CodesHCPCS

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.

Covered/Updated CPT CodesCPT

38230

CPT code added to align with policy criteria

Provider Actions and Billing

Billing Rule

Procedure coding for authorization

Transplant procedures must be submitted using the applicable CPT and HCPCS procedure codes when requesting prior authorization or submitting claims.

Use CPT and HCPCS codes listed in the policy for authorization requests and claims.
Include the specific procedure code that corresponds to the transplantation service provided.

Prior Authorization

Prior authorization and coding update

Prior authorization is required per plan benefit and policy adjudication. CPT code 38230 has been added to the policy and should be included in authorization requests when applicable.

Prior authorization requirements apply according to the member's plan and this medical policy.

Background

Hematopoietic cell transplantation (HCT) is a procedure in which hematopoietic stem cells are infused intravenously to restore marrow function after high‑dose cytotoxic therapy. Autologous HCT uses the patient’s own hematopoietic stem cells, collected and re‑infused following high‑dose therapy; immunologic compatibility between donor and recipient is not a consideration. Allogeneic HCT uses hematopoietic stem cells from a donor and requires human leukocyte antigen (HLA) compatibility; conditioning regimens historically have been myeloablative, while reduced‑intensity conditioning (RIC) uses lower‑dose regimens intended to limit treatment‑related morbidity and allow graft‑versus‑tumor effects.

Definitions

Autologous HCT — definition

DefinitionAutologous HCT: Hematopoietic stem cells obtained from the transplant recipient and re‑infused after high‑dose therapy; immunologic compatibility is not an issue.

Source tissueHematopoietic stem cells may be harvested from bone marrow, peripheral blood, or umbilical cord blood.

PurposeInfusion to restore bone marrow and immune function after bone‑marrow‑toxic cytotoxic therapy with or without whole‑body radiotherapy.

Compatibility noteImmunologic compatibility between infused cells and recipient is not required for autologous transplants.

Allogeneic HCT and Reduced‑Intensity Conditioning — definitions

DefinitionAllogeneic HCT: Hematopoietic stem cells obtained from a donor; immunologic compatibility (HLA matching) between donor and recipient is a critical factor for success.

Policy Summary

PayerPremera Bluecross

PolicyHematopoietic Cell Transplantation for Solid Tumors in Adults

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionUse the referenced CPT and HCPCS codes when requesting prior authorization and document FDA regulatory status and plan-specific benefit application.

SourceLink

On This Page

When applicable, include CPT 38230 in authorization and claims submissions (bone marrow harvesting for transplantation; allogeneic).

Documentation Required

Coding documentation

Providers must document the use of the transplantation procedures with the referenced CPT and HCPCS codes in the medical record and on claim submissions.

Report the most specific CPT/HCPCS code that describes the service performed.
Maintain clinical documentation that supports the selected code and medical necessity.
Note AMA/CMS copyright statements accompany CPT/HCPCS descriptions.

Documentation Required

Regulatory and member benefit documentation

Document the regulatory status of hematopoietic stem cell products and that they meet applicable FDA requirements under 21 CFR parts 1270 and 1271 when relevant to coverage adjudication.

Include evidence that stem cell products meet FDA requirements when applicable.
Confirm and document whether products are regulated human cells or tissues per CBER guidance.
Providers should reference member benefit language for plan-specific regulatory or coverage conditions.

Note

State/trial coverage considerations

State mandates or participation in voluntary NIH clinical trial coverage programs may supersede this policy for autologous bone marrow/stem cell transplantation performed as part of NIH‑approved clinical trials.

Verify state-specific mandates that require coverage for autologous bone marrow transplantation in NIH‑approved clinical trials.
Confirm whether the member's plan participates in voluntary NIH clinical trial coverage programs and document trial approval status in authorization requests.

Prior Authorization

Trial-first recommendation for Ewing sarcoma

For relapsed Ewing sarcoma, national expert guidance recommends reserving autologous HCT with myeloablative conditioning for use only within clinical trials; include trial enrollment documentation when requesting authorization.

If autologous HCT is proposed for relapsed Ewing sarcoma, indicate whether treatment is part of a clinical trial and provide trial identifiers and supporting documentation.
Authorization may be denied if proposed outside of a clinical trial in line with the Tumor Board recommendation and policy investigational stance for many adult solid tumors.

HLA compatibilityCompatibility is established by typing HLA‑A, ‑B, and ‑DR loci using cellular, serologic, or molecular techniques; an acceptable donor will match at all or most HLA loci.

Reduced-Intensity Conditioning (RIC)RIC refers to pretransplant use of lower doses of cytotoxic drugs or less intense radiotherapy than full‑dose myeloablative regimens, aiming to reduce morbidity and nonrelapse mortality while enabling graft‑versus‑malignancy effects.

RIC characteristicsRIC regimens vary from nearly myeloablative to minimally myeloablative with lymphoablation; they initially produce mixed donor‑host chimerism with most patients converting to full‑donor chimerism.

Regulatory note — Hematopoietic stem cells / HCT

Regulatory frameworkHematopoietic stem cells and other human cells/tissues intended for implantation, transplantation, or infusion are regulated by the FDA under 21 CFR parts 1270 and 1271.

Regulating centerRegulation is administered by the FDA Center for Biologics Evaluation and Research (CBER).

InclusionHematopoietic stem cells are explicitly included under these human cells/tissues regulations.