Currentpriority healthPolicy 91066

STEM CELL OR BONE MARROW TRANSPLANTATION

Defines medical necessity criteria, covered indications, exclusions, preauthorization and facility requirements for allogeneic and autologous hematopoietic cell transplants, and coverage details for pre-, peri- and post-transplant services. Applies to Priority Health members, subject to plan benefits.

Policy Summary

Payerpriority health

PolicySTEM CELL OR BONE MARROW TRANSPLANTATION

Policy CodePolicy 91066

Change TypeRemoved exclusions; revised age criterion; added tandem therapy criteria

Effective DateJun 1, 2026

Next Review Date

Key ActionAll bone marrow, peripheral stem cell, or other blood cell transplants must be pre-authorized by Priority Health and performed at an approved facility; submit requests on the specified prior authorization form.

POLICY UPDATE CHANGES

Removed exclusion for persistent or active substance or alcohol abuse (I.A.2.a).

Stem Cell Transplant for Autoimmune Diseases: removed lower age limit of 18 for autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis.

Stem Cell Transplant for Multiple Myeloma, Amyloidosis or POEMS syndrome: added risk-adapted criteria for tandem therapy for multiple myeloma.

ManyListed Covered Indications (selected)

MultipleListed Investigational/Not Covered Indications

1 yearStandard follow-up coverage at transplant facility

73%Pooled progression-free survival after AHSCT (MS)

4%Transplant-related mortality after AHSCT (MS)

05/2026Most recent committee review

Coverage Summary

Priority Health's medical policy addresses coverage, indications, eligibility and administrative requirements for allogeneic and autologous hematopoietic cell transplantation (including bone marrow, peripheral stem cell, cord blood and other blood cell transplants) for specified clinical conditions. Coverage is subject to the member's specific plan benefits, applicable medical necessity criteria, and preauthorization requirements and approved facility stipulations described in the policy. Group- or plan-specific documents and benefit language govern the final determination of coverage.

Medical-Necessity Criteria

General Coverage Criteria for Stem Cell/Bone Marrow/Other Blood Cell Transplants

Allogeneic or Autologous Bone Marrow, Peripheral Stem Cell, or other Blood Cell Transplants are covered for specific non-experimental indications when proven effective and when general guidelines are met.

ALL of the following

Adequate major organ function and lack of major systemic complications including adequate liver, cardiac, pulmonary, and renal function.
Predicted ability to tolerate the surgical procedure and post-transplant immunosuppression regimen and potential complications.
Emotional and psychiatric stability, including a strong family or alternative support network (documented by formal social work evaluation).
Ability to understand the risks of the procedures.

Not covered when ANY of the following are present

Presence of psychiatric disease that would interfere with ability to comply with pre- or post-transplant therapeutic regimen.
Significant history of medical noncompliance.
Unwillingness or inability to adhere to post-transplant lifestyle restrictions and medical regimen.

Administrative/coverage requirements: Administrative and facility requirements

All transplants must be pre-authorized by Priority Health and performed at a Priority Health approved facility; requests submitted on the Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant prior authorization form. Transplant referrals are directed to Priority Health's network or contracted networks. Transportation and lodging for patient, donor or family are not covered unless specified in coverage documents. Experimental, investigational, or unproven transplants are not covered unless exceptions under specified experimental/clinical trials policies are met (policies #91117, #91448, #91606).

Covered Services Included with an Approved Transplant

An approved transplant includes the following services:

ALL of the following

Pre-transplant care, including the transplant evaluation. One evaluation per transplant; second opinion consult for candidacy may be approved at contracted/in-network facility if previously turned down.
Transplant care, facility, and professional fees.
Harvesting of donor; Priority Health will cover donor fees for transplant recipients who are members unless donor fees are covered by another health plan.
Post-transplant immunosuppressant drug therapy if the group has outpatient prescription drug coverage.
Post-transplant follow-up coverage:

Condition-specific Medical Necessity Criteria (Selected examples present in part 1)

Coverage decisions by indication. Each indication lists whether autologous/allogeneic/tandem/non-myeloablative are covered or investigational.

Non-malignant conditions (Allogeneic may be considered medically necessary for selected disorders): Allogeneic bone marrow transplants may be considered medically necessary for selected patients with listed non-malignant disorders.

Includes sickle cell anemia with prior stroke or high risk and HLA-identical donor; severe aplastic anemia with platelets < 20 x 10^9/L, granulocytes < 0.5 x 10^9/L, reticulocytes < 1% and failed ATG; homozygous beta-thalassemia; Wiskott-Aldrich; SCID; Chediak-Higashi; infantile malignant osteopetrosis; mucopolysaccharidoses in neurologically intact patients; mucolipidoses after failed conventional therapy; Kostmann's syndrome; leukocyte adhesion deficiencies; X-linked lymphoproliferative syndrome.

Autoimmune disease: Multiple Sclerosis (autologous HSCT): Autologous hematopoietic stem cell transplantation for relapsing-remitting multiple sclerosis when all criteria are met.

Selection: relapsing-remitting MS; breakthrough disease activity despite high-efficacy disease-modifying therapy evidenced by either two or more clinical relapses within prior 12 months OR one relapse plus an MRI gadolinium-enhancing lesion at a separate time within prior 12 months; EDSS 2.0-6.0; age <45; disease duration <10 years. Other autoimmune diseases listed are considered experimental/investigational and not covered.

Medical Necessity Review / Individual Case Review

Coverage decisions for investigational or unproven treatments:

Medical necessity review and individual case review

Prior authorization may be required for certain drugs, devices, services and procedures; providers must submit request demonstrating medical necessity.
Individual case review may allow coverage for care or treatment that is investigational yet promising; requests require prior plan approval and determination by a Priority Health medical director or clinical pharmacist.
Exception review possible if condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

Authorization resources

To access Evicore, InterQual, or TurningPoint guidelines use Priority Health Prism Authorization Criteria Lookup per Provider Manual instructions.

Application to Products / Plan Types

This policy applies to the following plan types unless superseded by plan-specific documents:

Plan applicability

HMO/EPO: applies to insured HMO/EPO plans.
POS: applies to insured POS plans.
PPO: applies to insured PPO plans; consult plan documents for state mandated benefits.
ASO: for self-funded plans, consult individual plan documents.
INDIVIDUAL: consult individual insurance policy.

Coding

ICD-10 Codes that may support medical necessity (not all inclusive)ICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast
C50.012	Malignant neoplasm of nipple and areola, left female breast
C50.021	Malignant neoplasm of central portion of right female breast
C50.022	Malignant neoplasm of central portion of left female breast
C50.031	Malignant neoplasm of upper-inner quadrant of right female breast
C50.032	Malignant neoplasm of upper-inner quadrant of left female breast
C50.041	Malignant neoplasm of lower-inner quadrant of right female breast
C50.042	Malignant neoplasm of lower-inner quadrant of left female breast
C50.111	Malignant neoplasm of nipple and areola, right male breast
C50.112	Malignant neoplasm of nipple and areola, left male breast

1–10 of 40

1/4

CPT/HCPCS Codes (No prior authorization required for In-Network providers)CPT|HCPCSCovered

38240	Bone marrow harvest for transplantation; allogeneic
38241	Bone marrow harvest for transplantation; autologous
38206	Bone marrow or blood-derived stem cell transplantation; allogeneic, unrelated donor
38207	Bone marrow or blood-derived stem cell transplantation; allogeneic, related donor
88367	Immunohistochemistry, each additional single antibody stain procedure (list separately in addition to code for primary procedure)

Codes Not Medically NecessaryCPT|HCPCSNot Covered

0262T	Autologous stem cell transplantation services, including cell collection, preparation, and reinfusion (investigational/experimental for many indications)
0168T	Stem cell infusion, non-hematopoietic, investigational

Related CMS LCD/NCD references citedmixed

LCD	Local Coverage Determinations relevant to hematopoietic stem cell transplantation as applicable
NCD	National Coverage Determinations relevant to bone marrow and hematopoietic stem cell transplantation

Provider Actions & Administrative Requirements

Prior Authorization

Preauthorization required for all transplants

All bone marrow, peripheral stem cell, or other hematopoietic cell transplants require preauthorization by Priority Health and must be performed at a Priority Health–approved facility. Submit requests using the Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant prior authorization form.

Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant prior authorization form

Prior Authorization

Pre-transplant evaluation limit

One pre‑transplant evaluation is covered per transplant. A second transplant evaluation (second opinion) will be approved at a contracted or in‑network transplant facility only if the member has been previously turned down for transplant.

Background & Evidence

This policy was developed with clinical input and is based on review of published literature, professional guidelines (e.g., NCCN, EBMT, ASTCT) and applicable CMS determinations. Priority Health reviews and updates medical policies periodically; however, actual coverage determinations remain subject to each member's plan language and benefit terms.

Evidence / Guideline	Notes/Key data
High-risk neuroblastoma guideline	References Children's Oncology Group Neuroblastoma Risk Classifier (version 2). Policy: autologous SCT covered for high-risk neuroblastoma; max of three tandem autologous HSCTs covered.
MS HSCT evidence requirements	Selection criteria listed: RRMS with breakthrough activity despite high-efficacy DMT (>=2 relapses in prior 12 months or 1 relapse plus gadolinium-enhancing MRI lesion), EDSS 2.0-6.0, age <45, disease duration <10 years. RCT (Burt et al. 2019): hazard ratio for progression 0.07 (95% CI 0.02–0.24; P<.001). Pooled AHSCT PFS 73% (95% CI 69%–77%), overall survival 94% (95% CI 91%–96%), transplant-related mortality 4% (95% CI 2%–6%).
Cardiac autologous bone marrow cell therapy evidence	Systematic reviews/meta-analyses show mixed/limited benefit; intramyocardial BMC transplantation increased LVEF by 4.91% (95% CI 2.84%–6.99%) and reduced LVESV by 10.66 mL (95% CI −18.92 to −2.41 mL). Intracoronary BMC in AMI: LVEF increase 2.53% (95% CI 0.67%–4.39%) at 3–6 months. Policy lists as experimental/unproven and excluded from coverage.
Crohn's disease HSCT evidence	2024 systematic review/meta-analysis found mean CDAI decrease −217.53 ±14.3; RCT (ASTIClite) halted for safety concerns with serious adverse reactions (eg, thrombotic microangiopathy, renal failure, deaths); policy classifies autologous SCT for Crohn's as experimental/unproven.
Age-related macular degeneration stem cell evidence	Meta-analysis: BCVA risk ratio at 6 months RR=17.00 (95% CI 6.08–47.56); small studies—policy lists AMD stem cell as experimental/unproven.

Not Covered / Experimental Indications

Other non-covered indications (listed experimental/unproven exclusions)

Other non-covered indications listed as experimental, investigational, or unproven:

Excluded / investigational indications

Autologous stem cell transplantation for Crohn's disease.
Stem cell therapy for erectile dysfunction.
Autologous bone marrow cells, including transendocardial delivery, for coronary artery disease, left ventricular dysfunction, heart failure or angina.
Age-related macular degeneration.

Definitions

Tandem Transplantation: Two or more planned courses of high-dose chemotherapy with stem cell support, typically given at intervals of two to six months contingent on recovery. Responsive: Tumor showing either a complete or partial remission. Partial remission: At least a 50% reduction in tumor burden. Relapse: Re-appearance of disease after initial therapy and attainment of complete response. Refractory disease: Failure to attain a complete or partial response (primary or secondary). Myeloablative Chemotherapy: High-dose chemotherapy that destroys bone marrow cells and is usually followed by transplant to rebuild marrow. Non-myeloablative transplant (mini-transplant): Lower, less toxic doses of chemotherapy and/or radiation (reduced intensity conditioning) followed by donor stem cell infusion.

Revision History

05/2026committee_reviewLatest

Removed exclusion for persistent or active substance or alcohol abuse (I.A.2.a) — material change

05/2026policy_revision

Stem Cell Transplant for Autoimmune Diseases: removed lower age limit of 18 for autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis — material change

05/2026policy_addition

Stem Cell Transplant for Multiple Myeloma, Amyloidosis or POEMS syndrome: added risk-adapted criteria for tandem therapy for multiple myeloma — material change

Policy Summary

Payerpriority health

PolicySTEM CELL OR BONE MARROW TRANSPLANTATION

Policy CodePolicy 91066

Change TypeRemoved exclusions; revised age criterion; added tandem therapy criteria

Effective DateJun 1, 2026

Next Review Date

On This Page

Follow-up care and services covered at the transplant facility for one year following transplant for both contracted and non-contracted facilities; beyond one year follow-up care covered at contracted transplant facilities, and for non-contracted facilities only physician services are covered while testing, labs, and imaging are covered in-network only.

Solid tumors in adults: Autologous or allogeneic HSCT for listed adult solid tumors is considered experimental and investigational (not covered).

Tumors listed include bile duct, breast, CNS tumors (astrocytoma, choroid plexus tumors, ependymoma, gliomas, oligodendroglioma), cervix, colon, epithelial ovarian, esophagus, gallbladder, kidney, lung, melanoma, nasopharynx, pancreas, paranasal sinus, prostate, rectum, renal cell carcinoma, soft tissue sarcomas, stomach, thymus, thyroid, uterus.

Childhood solid tumors (autologous HSCT covered): High-dose chemotherapy followed by autologous HSCT covered for relapsed Wilms' tumor, metastatic non-CNS retinoblastoma, and relapsed/progressive Ewing family tumors.

Neuroblastoma: Autologous SCT covered for high-risk neuroblastoma; maximum of three tandem autologous HSCTs covered. Allogeneic SCT from appropriately-matched HLA donor after high-dose chemotherapy covered when individual not candidate for autologous HSCT.max 3 tandem HSCTs

High Risk Neuroblastoma defined by Children's Oncology Group Neuroblastoma Risk Classifier (version 2).

PNET and Ependymoma: Autologous SCT is covered for PNET (including medulloblastoma and pineoblastoma); allogeneic SCT is investigational for PNET. Autologous SCT covered for ependymoma if patient ineligible for radiotherapy; allogeneic SCT investigational for ependymoma.

Germ Cell Tumors: Single or tandem autologous SCT covered for relapsed or refractory testicular and ovarian germ cell tumors. Autologous SCT as front-line therapy and allogeneic SCT are investigational/not covered. Note: SCT is not covered for epithelial ovarian cancer.

Hodgkin's Disease: High-dose chemotherapy with autologous or allogeneic stem cell support may be covered for refractory, primary progressive or recurrent Hodgkin's disease. Nonmyeloablative allogeneic SCT covered for relapsed/refractory Hodgkin disease following a prior SCT. Tandem stem cell transplant for Hodgkin's disease is investigational (not covered).

Non-Hodgkin's Lymphomas (NHL): Autologous or allogeneic stem cell covered for relapsed or primary refractory NHL. High-dose chemo with stem cell support investigational as initial therapy. Non-myeloablative allogeneic HCT may be covered when reduced intensity regimen preferred. Tandem transplants experimental/investigational.

Myelofibrosis: Allogeneic (ablative and non-myeloablative) SCT covered when any: transfusion dependent (RBC or platelet); resistant to conservative therapy; intermediate or high risk MF. Repeat allogeneic SCT medically necessary for primary graft failure or relapse. Autologous SCT investigational.

Myelodysplastic Syndrome (MDS): Allogeneic (ablative and non-myeloablative) SCT covered for intermediate- or high-risk MDS when not responded to prior therapy and with available HLA-matched donor. Repeat allogeneic SCT covered for primary graft failure or failure to engraft; repeat allogeneic SCT for relapsed MDS considered experimental. Autologous SCT investigational.intermediate- or high-risk

Chronic Myelogenous Leukemia (CML): High-dose chemotherapy with allogeneic stem cell support is covered for CML. High-dose chemo with autologous support is investigational for CML.

Acute Myelogenous Leukemia (AML): Autologous or allogeneic SCT covered for AML in first complete remission, primary refractory AML, or relapsed AML (ablative and non-myeloablative). Repeat SCT covered for primary graft failure, failure to engraft, or relapse after prior SCT. Repeat SCT for persistent/progressive disease investigational. Tandem SCT for AML investigational.

Acute Lymphocytic Leukemia (ALL): Allogeneic SCT covered for ALL including primary refractory ALL except for refractory relapse unresponsive to >=3 months adequate chemotherapy. Non-myeloablative allogeneic HCT covered for members with no persistent disease who meet selection criteria; persons with persistent disease not candidates for mini-allograft. Second myeloablative allogeneic HSCT covered when relapse >6 months after first allogeneic SCT. Autologous SCT covered where no suitable donor is available. Tandem SCT investigational.relapse >6 months for 2nd myeloablative allograft

Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL): Allogeneic SCT covered for CLL not responsive to standard therapy. Autologous SCT covered for CLL in individuals in complete or good partial remission.

Multiple Myeloma, Amyloidosis, POEMS: Multiple Myeloma: autologous SCT covered for active symptomatic MM after response to primary therapy or refractory with relapse/progressive disease. Second or third autologous SCTs covered in specified relapsed/progressive scenarios. Tandem autologous or autologous->allogeneic considered medically necessary if planned 1st and 2nd transplants within a 6-month period and member high risk for progression/relapse. Allogeneic SCT covered for progressive disease following autologous HSCT. Amyloidosis: autologous stem cell support covered; second autologous, tandem autologous, and allogeneic SCT are experimental and not covered. POEMS: autologous SCT covered.tandem timing: within 6-month period

Nonmyeloablative Allogeneic Transplant (mini-transplant) - covered applications: Nonmyeloablative allogeneic HCT may be considered medically necessary for listed conditions for patients meeting selection criteria; other applications considered investigational.

Covered conditions include NHL, Hodgkin's, MDS, AML, CML, ALL, CLL, multiple myeloma, aplastic anemia, myelofibrosis, neuroblastoma, sickle cell anemia, thalassemia major.

Tandem Transplants: Tandem stem cell transplants may be covered for specific conditions if noted as covered in applicable sections; use for some conditions is considered experimental/investigational.

Umbilical Cord Blood Stem Cell Transplant (UCBSCT): UCBSCT covered in patients who meet all eligibility requirements for an allogeneic stem cell transplant; not covered for patients who do not meet selection criteria for allogeneic SCT.

Other non-covered indications (listed experimental/unproven exclusions): Listed experimental and unproven exclusions are not covered.

Includes autologous SCT for Crohn's disease; stem cell therapy for erectile dysfunction; autologous bone marrow cells including transendocardial delivery for coronary artery disease, LV dysfunction, heart failure or angina; age-related macular degeneration; amyotrophic lateral sclerosis; diabetes mellitus (type I); essential thrombocythemia; polycythemia vera; recessive dystrophic epidermolysis bullosa; retinitis pigmentosa; thrombotic thrombocytopenic purpura; spinal cord injury.

All determinations of coverage for experimental, investigational, or unproven treatment will be made by a Priority Health medical director or clinical pharmacist.

Prior authorization procedural note: Providers must submit requests demonstrating medical necessity when required; refer to Priority Health Provider Manual for requirements and processes.

MEDICARE: coverage determined by CMS; if no CMS determination, this policy applies.

MEDICAID/HEALTHY MICHIGAN PLAN special rules

Policy applies; coverage based on medical necessity criteria and appropriate coding on Michigan Medicaid Fee Schedule.
If discrepancy between this policy and Michigan Medicaid Provider Manual, the Provider Manual governs.
If discrepancy or lack of guidance in Provider Manual, Priority Health contract with Michigan Medicaid governs.
For Medical Supplies/DME/Prosthetics and Orthotics, refer to Michigan Medicaid Fee Schedule to verify coverage.

Plan conflict guidance: If there is a conflict between this policy and a plan document, the provisions of the plan document will govern.

Billing Rule

Post-transplant follow-up limits

Follow‑up care at the transplant facility is covered for one year following the transplant for both contracted and non‑contracted facilities. Beyond one year post‑transplant, follow‑up is covered only at contracted transplant facilities. For non‑contracted facilities beyond one year, only physician services are covered; testing, labs, and imaging are covered in‑network only.

Documentation Required

Support network and psychosocial evaluation

Emotional and psychiatric stability and a strong family or alternative support network must be documented. A formal social work evaluation is required to demonstrate adequate support and the member's ability to comply with pre‑ and post‑transplant therapeutic regimens.

Prior Authorization

Prior authorization requirement for certain services

Priority Health uses external clinical criteria/decision support (Evicore/InterQual/Turning Point) for prior authorization determinations. These guidelines and criteria are accessible via the Priority Health Prism Authorization Criteria Lookup.

Access Evicore/InterQual/Turning Point guidelines via Priority Health Prism Authorization Criteria Lookup

Documentation Required

Individual case review documentation

For exception requests or individual case reviews, document the clinical rationale and supporting evidence that the member's condition is terminal, chronic, or severe and why standard criteria should not apply. Include pertinent clinical notes, diagnostic testing, and a clear statement of the requested exception.

Billing Rule

In-Network no prior authorization list

The following CPT/HCPCS codes are considered in‑network without prior authorization when billed by an in‑network transplant facility. Include appropriate supportive ICD‑10 diagnosis codes with claims.

CPT/HCPCS codes: 38205, 38206, 38207, 38208, 38240, 38241, 38242, 38243, 38244, 38245, 38246, 38207-59 (as applicable)
Include supportive ICD‑10 codes on the claim

Denial Risk

Not medically necessary codes

The following codes are considered not medically necessary for the services described and may be denied if billed: 0263T, 0264T, 0265T, S2150. Providers should avoid billing these codes for transplant services to reduce denial risk.

0263T
0264T
0265T
S2150

Amyotrophic lateral sclerosis.

Diabetes mellitus (type I).

Essential thrombocythemia.

Recessive dystrophic epidermolysis bullosa.

Retinitis pigmentosa.

Thrombotic thrombocytopenic purpura.

Not medically necessary codes note: Specific procedure codes related to some excluded therapies are designated Not Medically Necessary per coding section (see policy).

Treatments that the policy identifies as experimental, investigational, or unproven are generally not covered. Individual case review (prior plan approval and review by a Priority Health medical director or clinical pharmacist) may be considered for investigational but potentially promising interventions when documentation supports exception criteria (for example, terminal illness or severe disabling disease).

06/01/2026effective_date

Policy effective date set to 06/01/2026