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Currentpriority healthPolicy 91066

STEM CELL OR BONE MARROW TRANSPLANTATION

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Defines medical necessity criteria, coverage, and facility/authorization requirements for allogeneic and autologous hematopoietic stem cell, bone marrow, and other blood cell transplants for Priority Health members.

Policy Summary

Payerpriority health

PolicySTEM CELL OR BONE MARROW TRANSPLANTATION

Policy CodePolicy 91066

Change TypeNo material clinical or coverage changes

Effective DateJun 1, 2026

Last ReviewMay 1, 2026

Next Review DateMay 1, 2026

Key ActionObtain prior authorization and ensure transplant is scheduled at a Priority Health approved facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearfollow-up duration

<45MS age limit

3neuroblastoma tandem max

Requiredpre-auth requirement

No prior authin-network HPC auth

Often investigationaltandem transplants stance

Coverage Criteria and Indications

General Coverage Criteria

Covered when ALL of the following general candidate criteria are met

General candidacy requirements: Member must have adequate major organ function (adequate liver, cardiac, pulmonary, and renal function); predicted ability to tolerate the surgical procedure and post-transplant immunosuppression; emotional and psychiatric stability with documented formal social work evaluation and a strong support network; and the ability to understand and consent to the risks of the procedure.

From General Coverage Criteria (chunks 3–4)

General Exclusions / Contraindications

Transplant is not covered when ANY of the following are present

Exclusionary conditions: Presence of psychiatric disease that would interfere with the member's ability to comply with the pre- or post-transplant therapeutic regimen; significant history of medical noncompliance; or unwillingness or inability to adhere to post-transplant lifestyle restrictions and medical regimen.

From General Exclusions / Contraindications (chunk 4)

Policy Summary

Payerpriority health

PolicySTEM CELL OR BONE MARROW TRANSPLANTATION

Policy CodePolicy 91066

Change TypeNo material clinical or coverage changes

Effective DateJun 1, 2026

Last ReviewMay 1, 2026

Next Review DateMay 1, 2026

Key ActionObtain prior authorization and ensure transplant is scheduled at a Priority Health approved facility.

SourceLink

On This Page

Non-malignant Indications

Allogeneic transplants are covered for selected non-malignant disorders when specific condition criteria are met

Non-malignant indications (examples): Allogeneic bone marrow transplantation is covered for selected non-malignant disorders, including: sickle cell anemia (children/young adults with prior stroke or at high risk for stroke/end-organ damage with an HLA-identical donor), severe or very severe aplastic anemia (including congenital forms) meeting specified cytopenia criteria and failed antithymocyte globulin, homozygous beta-thalassemia (thalassemia major), Wiskott-Aldrich syndrome, severe combined immunodeficiencies, Chediak-Higashi syndrome, infantile malignant osteopetrosis, selected mucopolysaccharidoses and mucolipidoses in patients who are neurologically intact or have failed conventional therapy, Kostmann's syndrome, leukocyte adhesion deficiencies, and X-linked lymphoproliferative syndrome.

From Non-malignant Indications list (chunk 9)

MS (Autologous HSCT) Criteria

Autologous HSCT for multiple sclerosis is covered when ALL of the following are met

MS criteria: Relapsing-remitting multiple sclerosis; evidence of breakthrough inflammatory disease activity despite ongoing high-efficacy disease-modifying therapy, demonstrated by either: (1) two or more clinical relapses at separate times within the previous 12 months, OR (2) one clinical relapse plus MRI gadolinium-enhancing lesion(s) at a separate time within the previous 12 months; Expanded Disability Status Scale (EDSS) score of 2.0 to 6.0 (ambulatory); age less than 45 years; and disease duration less than 10 years.EDSS 2.0–6.0; age <45; disease duration <10 years

MS AHSCT inclusion criteria (chunk 10)

Adult Solid Tumors — Not Covered

Autologous or allogeneic HSCT for adult solid tumors

Adult solid tumors — investigational: Autologous or allogeneic hematopoietic stem cell transplantation (ablative or non-myeloablative) for the listed adult solid tumors (including but not limited to bile duct, breast, CNS tumors, cervix, colon, epithelial ovarian, esophagus, gallbladder, kidney, lung, melanoma, nasopharynx, pancreas, paranasal sinus, prostate, rectum, renal cell carcinoma, soft tissue sarcomas, stomach, thymus, thyroid, and uterus) is considered experimental, investigational, or unproven and is not a covered benefit.

Adult solid tumors — Not Covered (chunk 11)

Childhood Solid Tumors

Covered pediatric solid tumors when criteria met

Pediatric solid tumor indications: High-dose chemotherapy followed by autologous hematopoietic stem-cell transplantation is covered for relapsed Wilms' tumor; metastatic non-central nervous system retinoblastoma; and relapsed or progressive Ewing family of tumors.

Childhood solid tumor coverage (chunk 12)

Neuroblastoma

Neuroblastoma coverage

Neuroblastoma: Autologous stem-cell transplantation (SCT) is a covered benefit for high-risk neuroblastoma; up to a maximum of three tandem autologous HSCTs are covered. Allogeneic SCT from an appropriately-matched HLA donor is covered when the patient is not a candidate for autologous HSCT.maximum 3 tandem autologous HSCTs

Neuroblastoma policy (chunk 13)

PNET and Ependymoma

PNET and ependymoma coverage stance

PNET/medulloblastoma: Autologous stem cell transplantation is a covered benefit for primitive neuroectodermal tumors (PNET), including medulloblastoma and pineoblastoma; allogeneic SCT is considered experimental and investigational for PNET.

PNET coverage (chunk 15)

Ependymoma: Autologous stem cell transplantation is covered for ependymoma when the patient is ineligible for radiotherapy; allogeneic SCT is considered experimental and investigational for ependymoma.

Ependymoma coverage (chunk 15)

Germ Cell Tumors

Germ cell tumors coverage

Germ cell tumors: Single or tandem autologous hematopoietic stem-cell transplantation is covered for relapsed or refractory testicular and ovarian germ cell tumors. Autologous SCT as front-line therapy and allogeneic SCT are considered experimental and not covered. Note: SCT is not covered for epithelial ovarian cancer per the adult solid tumor exclusions.

Germ cell tumor specifics (chunk 16)

Hodgkin's Disease

Hodgkin's disease coverage

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 is covered for relapsed or refractory Hodgkin disease following a prior SCT. Tandem stem cell transplant for Hodgkin's disease is considered investigational.

Hodgkin's disease rules (chunk 17)

Non-Hodgkin's Lymphomas

Non-Hodgkin's lymphoma coverage

NHL: Autologous or allogeneic stem cell transplantation is a covered benefit for relapsed or primary refractory non-Hodgkin's lymphoma (NHL). High-dose chemotherapy with stem cell support as initial therapy for NHL is investigational. Non-myeloablative allogeneic HCT may be covered for relapsed or primary refractory NHL when the transplant center prefers reduced-intensity conditioning. Tandem strategies (auto-auto or auto-allo) are considered experimental and investigational for NHL.

NHL coverage (chunk 18)

Myelofibrosis

Myelofibrosis coverage

Myelofibrosis indications: Allogeneic (ablative and non-myeloablative) stem cell transplantation is covered when ANY of the following are met: the individual is transfusion (RBC or platelet) dependent; OR the individual is resistant to conservative therapy; OR the individual has intermediate- or high-risk myelofibrosis. Repeat allogeneic transplantation is medically necessary for primary graft failure or relapse. Autologous SCT is considered experimental for myelofibrosis.

Myelofibrosis criteria (chunk 19)

Non-Hodgkin's Lymphoma (NHL)

Covered indications and investigational uses for stem cell transplant in NHL.

Covered: Autologous or allogeneic stem cell transplant is a covered benefit for relapsed or primary refractory non-Hodgkin's lymphoma (NHL).

(chunk 18)

Not initial therapy: High-dose chemotherapy with autologous or allogeneic stem cell support is investigational as initial therapy for all NHL.

(chunk 18)

Non-myeloablative option: Non-myeloablative allogeneic hematopoietic cell transplantation may be covered for relapsed or primary refractory NHL when a reduced intensity regimen is preferred by the transplant center.

(chunk 18)

Tandem investigational: Tandem autologous (auto-auto) or auto-allo transplants are considered experimental and investigational for NHL.

(chunk 18)

Myelofibrosis (MF)

Allogeneic transplant coverage when any of listed clinical criteria are met.

Covered when ANY of the following are met: Allogeneic (ablative and non-myeloablative) stem cell transplantation is covered when the individual is transfusion (RBC or platelet) dependent; OR resistant to conservative therapy; OR has intermediate- or high-risk myelofibrosis.

(chunk 19)

Repeat transplant: Repeat allogeneic transplant is medically necessary for primary graft failure or relapse.

(chunk 19)

Autologous investigational: Autologous stem cell transplantation is considered experimental and investigational for myelofibrosis.

(chunk 19)

Myelodysplastic Syndrome (MDS)

Allogeneic transplant coverage with donor and prior therapy conditions.

Covered: Allogeneic (ablative and non-myeloablative) stem cell transplantation is covered for intermediate-risk or high-risk myelodysplastic syndrome (MDS) when the individual has not responded to prior therapy and has an available HLA-matched donor.

(chunk 20)

Repeat transplant: A repeat allogeneic (ablative or non-myeloablative) stem cell transplant is a covered benefit for primary graft failure or failure to engraft.

(chunk 20)

Repeat for relapse investigational: A repeat allogeneic SCT is considered experimental for individuals with MDS who have relapsed.

(chunk 20)

Autologous investigational: Autologous stem cell transplantation is considered experimental and investigational for MDS.

(chunk 20)

Chronic Myelogenous Leukemia (CML)

Allogeneic covered: High-dose chemotherapy with allogeneic stem cell support is a covered benefit for the treatment of chronic myelogenous leukemia (CML).

(chunk 21)

Autologous investigational: High-dose chemotherapy with autologous stem cell support is considered investigational as a treatment of CML.

(chunk 21)

Acute Myelogenous Leukemia (AML)

Covered indications: Autologous or allogeneic stem cell transplant is covered for AML in first complete remission, primary refractory AML, or relapsed AML; both ablative and non-myeloablative transplants are covered for these indications.

(chunk 22)

Repeat transplant covered: A repeat autologous or allogeneic hematopoietic cell transplantation (ablative or mini-allograft) is covered for primary graft failure, failure to engraft, or relapse after prior transplant.

(chunk 22)

Repeat for persistent disease investigational: A repeat autologous or allogeneic stem cell transplantation for persistent or progressive disease is considered experimental and investigational.

(chunk 22)

Tandem investigational: Tandem stem cell transplant for AML is considered investigational and not a covered benefit.

(chunk 22)

Acute Lymphocytic Leukemia (ALL)

Allogeneic covered: Allogeneic stem cell transplantation is covered for the treatment of ALL, including primary refractory ALL, except for refractory relapse unresponsive to three or more months of adequate chemotherapy.

(chunk 23)

Non-myeloablative covered: Non-myeloablative allogeneic HCT (mini-allograft) is covered for ALL patients with no persistent disease who meet selection criteria; persons with persistent disease should not be candidates for mini-allograft.

(chunk 23)

Second transplant covered: A second myeloablative allogeneic HSCT from an appropriately matched HLA donor is covered when relapsed disease occurs more than six months after the first allogeneic SCT.

(chunk 23)

Autologous covered when no donor: Autologous stem cell transplantation is covered for ALL when no suitable donor is available.

(chunk 23)

Tandem investigational: Tandem stem cell transplant for ALL is considered experimental and not a covered benefit.

(chunk 23)

Chronic Lymphocytic Leukemia (CLL) / Small Lymphocytic Lymphoma (SLL)

Allogeneic covered: Allogeneic stem-cell transplantation is a covered benefit for CLL that is not responsive to standard therapy.

(chunk 24)

Autologous covered: Autologous stem cell transplantation is a covered benefit for CLL in an individual in complete or good partial remission.

(chunk 24)

Multiple Myeloma, Amyloidosis, POEMS, and related rules

Disease-specific covered and investigational positions, and non-myeloablative transplant applicability.

Multiple Myeloma autologous covered: Autologous stem-cell transplantation is covered for active (symptomatic) multiple myeloma after response to primary therapy OR for refractory disease with relapse/progressive disease.

(chunk 25)

Second/third autologous allowed: A second autologous HCT may be medically necessary for responsive MM that relapsed after durable remission following autologous transplant; a third autologous SCT is covered for progressive disease following a previous autologous HSCT.

(chunk 25)

Tandem allowed in MM with timing: Tandem autologous or autologous followed by allogeneic transplantation is considered medically necessary if both planned transplants occur within a 6-month period and the member is high risk for progression/relapse.within 6 months

(chunk 25)

Allogeneic covered post-autologous failure: Allogeneic SCT from an appropriately-matched HLA donor is covered for active MM with progressive disease following autologous HSCT.

(chunk 25)

Amyloidosis autologous covered: Autologous stem cell support is covered for primary systemic amyloidosis (AL).

(chunk 26)

Amyloidosis investigational: Second autologous SCT, tandem autologous SCT, and allogeneic SCT are considered experimental and not covered for amyloidosis.

(chunk 26)

POEMS: Autologous SCT is a covered benefit for POEMS syndrome.

(chunk 27)

Non-myeloablative applicability: Non-myeloablative allogeneic transplantation may be considered medically necessary for listed malignancies and selected non-malignant conditions when patient selection criteria for high-dose/allogeneic SCT are met.

(chunk 27)

Umbilical Cord Blood Stem Cell Transplant (UCBSCT)

Conditional coverage: Umbilical cord blood stem cell transplant (UCBSCT) is covered only for patients who meet all eligibility requirements for an allogeneic stem cell transplant; UCBSCT is not covered for patients who do not meet patient selection criteria for allogeneic transplant.

(chunk 29)

Other Non-covered/Experimental Indications

Excluded indications: The following are considered experimental and unproven and are excluded from coverage: autologous SCT 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/angina; age-related macular degeneration; amyotrophic lateral sclerosis; type I diabetes mellitus; essential thrombocythemia; polycythemia vera; recessive dystrophic epidermolysis bullosa; retinitis pigmentosa; thrombotic thrombocytopenic purpura; spinal cord injury; and other listed indications.

Other Non-covered/Experimental Indications (chunk 30)

ALL special conditions

Persistent disease exclusion for mini-allograft: Persons with persistent disease should not be candidates for a non-myeloablative (mini-allograft) transplant.

ALL special condition (chunk 23)

aHSCT for Crohn's disease — evidence and risk considerations

Evidence indicates possible benefit in refractory Crohn's disease but with significant safety concerns — coverage decisions should balance efficacy against elevated risk of serious adverse events

Eligibility considerations: Patient has severe, refractory Crohn's disease who has failed conventional medical therapies (corticosteroids, aminosalicylates, immunosuppressants, biologics) and appropriate surgical management; alternatives exhausted and patient deemed fit for transplant after multidisciplinary evaluation.

(chunks 36–39)

Evidence of benefit: Systematic review/meta-analysis showed a mean decrease in Crohn Disease Activity Index (CDAI) of approximately -217.5 and benefit for perianal fistulas in pooled studies; some randomized data reported endoscopic improvement at 48 weeks in a small trial.

(chunks 37–38)

Safety concerns: Randomized trial data reported high frequency of serious adverse reactions including thrombotic microangiopathy, renal failure, pulmonary veno-occlusive disease, and treatment-related deaths, with substantially more serious adverse events in the HSCT arm than control.

(chunk 38)

Center and patient-level risk assessment: Decisions should be individualized accounting for age, disease severity, comorbidities, and center expertise (EBMT/JACIE); informed consent must address treatment-related mortality and late effects.

(chunk 39)

HSCT for multiple sclerosis — evidence synthesis

Randomized and guideline evidence support AHSCT in selected MS patients with inflammatory activity not responding to DMTs; patient selection and center expertise are emphasized.

Candidate characteristics: Patients with relapsing forms of MS (eg, RRMS) or progressive forms with superimposed inflammatory activity who have ongoing clinical relapses or MRI lesion activity despite treatment with available disease-modifying therapies (especially high-efficacy DMTs); ambulatory (EDSS ≤5.5 or EDSS 2.0–6.0 per policy), younger age (guidance cites <45 to <50 years), and disease duration less than approximately 10 years; consider aggressive MS earlier.EDSS ≤5.5 (guidelines); age <45–50; disease duration <10 years

Derived from EBMT/ASBMT/NMSS guidance and RCT populations (chunks 54–59)

Evidence of efficacy: Randomized trial (Burt et al., 2019) demonstrated reduced disease progression and improvement in EDSS at 1 year with nonmyeloablative HSCT compared to high-efficacy DMTs; systematic reviews report favorable pooled progression-free and relapse-free rates in selected cohorts.

(chunk 55 and related evidence summaries)

Safety: RCT reported no deaths and no grade 4 nonhematopoietic toxicities in the trial, but short-term risks, treatment-related mortality risk, long-term late effects, and importance of center experience are emphasized in guideline statements.

(chunks 55, 58–59)

Stem cell therapy for erectile dysfunction — investigational status

Available small studies and reviews suggest potential efficacy and safety signals but lack standardized protocols and controlled trials.

Evidence: Systematic reviews report potential benefit of stem cell therapies for erectile dysfunction across small heterogeneous studies, but protocols, dosing, and standardized techniques are lacking and higher-quality controlled trials are needed.

(chunks 41–42)

Guideline stance: Professional guidelines (AUA) consider intracavernosal stem cell therapy investigational.

(chunk 43)

Autologous bone marrow–derived cell therapy for cardiac disease — evidence summary

Multiple meta-analyses show mixed and generally modest benefits for LVEF and volumes; overall evidence insufficient for routine coverage outside research or specific protocols.

Efficacy signals: Meta-analyses report modest improvements in left ventricular ejection fraction (generally 2–5%) and reductions in LV volumes in selected trials, with greater benefit when combined with revascularization in some studies.

(chunks 46–48)

Safety and mortality: Meta-analyses found no consistent reduction in mortality or major adverse cardiovascular events; evidence heterogeneity and limited high-quality data restrict conclusions on routine clinical benefit.

(chunks 45–47)

Stem cell transplantation for age-related macular degeneration (AMD)

Small studies suggest possible improvement in best-corrected visual acuity for dry AMD, but data are from small samples and few randomized trials.

Evidence: Systematic review and meta-analysis of small studies (including randomized and nonrandomized trials) reported improvement in best-corrected visual acuity at 6 and 12 months after stem cell transplantation for dry AMD, but sample sizes are small and randomized evidence limited.

(chunks 49–50)

Limitations: Small sample sizes and limited randomized evidence limit confidence in generalizability and routine coverage.

(chunk 50)

Stem cell therapy for amyotrophic lateral sclerosis (ALS)

Preclinical data suggest survival benefit in animal models; human RCT evidence is limited and low certainty.

Evidence: Meta-analyses of preclinical studies show improved survival in animal ALS models; human randomized trial data are limited, heterogeneous, and of low certainty.

(chunks 51–52)

Clinical outcomes: Available RCT data report small or uncertain clinical benefit (eg, small changes in ALSFRS-R) with low-certainty evidence; overall evidence insufficient to support routine use.

(chunk 52–53)

AHSCT candidate selection (guideline-derived)

Guideline-recommended candidate profile for AHSCT (synthesized from cited position statements):

AHSCT candidate typical criteria: Patient has a relapsing form of MS (eg, RRMS) or progressive MS with superimposed inflammatory activity; ongoing clinical relapses or MRI lesion activity despite available DMTs (especially high-efficacy agents) OR aggressive MS with rapid disability accumulation; ambulatory status (EDSS ≤5.5 or EDSS 2.0–6.0 per policy); younger age (guidance commonly cites <45 years, some guidance up to <50 years); disease duration less than approximately 10 years; documented disability progression within prior 12 months when applicable; and suitability for transplant as determined by multidisciplinary evaluation.EDSS ≤5.5 (guidelines) / EDSS 2.0–6.0 (policy); age <45–50; disease duration <10 years

Derived from EBMT, ASBMT, and NMSS statements (chunks 58–59)

The policy states that experimental, investigational, or unproven transplants are not covered unless an exception applies under Priority Health's referenced exception or clinical trials policies. All bone marrow, peripheral stem cell, or other blood cell transplants require prior authorization and must be performed at a Priority Health–approved facility to avoid claim denial. Documentation supporting medical necessity (adequate major organ function, ability to tolerate procedure and immunosuppression, psychosocial evaluation and support, and informed consent regarding risks) is required for authorization decisions.

The policy lists specific procedures and conditions that are considered experimental/unproven and excluded from coverage (see the Non‑covered Indications and Amyloidosis sections). Examples include autologous SCT for Crohn's disease and many tandem SCT strategies when they are considered investigational. Tandem transplants and other procedures explicitly identified as investigational may be denied as not covered unless addressed by an applicable exception policy.

Because an RCT of HSCT for refractory Crohn's disease reported a high rate of serious unexpected adverse reactions (including thrombotic microangiopathy, renal failure, pulmonary veno‑occlusive disease) and treatment‑related deaths, the policy indicates that HSCT for Crohn's should generally be considered investigational or restricted outside of clinical trials or specialized centers. Prior authorization should require documentation of refractory disease after standard therapies and detailed risk counseling reflecting these safety concerns.

For Type 1 diabetes mellitus, the policy indicates HSCT remains investigational: although some trials report insulin independence, the conditioning regimens carry significant risks (including life‑threatening bone marrow aplasia and sepsis) that make HSCT unlikely to be useful as standard therapy.

No explicit additional coverage exclusions are listed in the provided excerpts; the policy includes a regulatory note advising providers to consult the U.S. Food & Drug Administration (FDA) Medical Device Databases for the most current device information when relevant.

The document states lists of diagnosis codes and coverage examples but notes that the lists are not all inclusive rather than presenting an exhaustive set of exclusions; no additional exclusive exclusion language is provided in this section.

In the extracted sections there are no explicit additional coverage exclusion criteria; several windows present ICD‑10 code lists intended to support medical necessity documentation rather than to define exclusions.

The included ICD‑10 code lists are presented as codes that may support medical necessity. In these excerpts no explicit exclusionary diagnosis criteria are stated — the content is primarily a collection of applicable ICD‑10 codes and ranges.

For the CPT/HCPCS and ICD‑10 codes shown, the policy specifies that No prior authorization is required for In‑Network providers for the listed hematopoietic progenitor cell and bone marrow procedure codes. The excerpt does not list other explicit coverage exclusions tied to those codes.

The policy considers HSCT for the enumerated adult solid tumors (see list) and other specified non‑covered indications to be investigational and not covered. For example, autologous or allogeneic HSCT for adult solid tumors such as breast, lung, colon, epithelial ovarian, melanoma, kidney, thyroid, and others is designated experimental/investigational and not covered.

High‑dose chemotherapy with autologous or allogeneic stem cell support is considered investigational as initial therapy for non‑Hodgkin's lymphoma and similar settings; tandem transplant strategies (auto‑auto or auto‑allo) are frequently considered experimental and are generally not covered except where the policy explicitly provides a medically necessary exception (for example, selected multiple myeloma circumstances).

The policy states that autologous HSCT for type 1 diabetes mellitus is not supported as standard therapy because the risks of conditioning outweigh benefits (see Type 1 diabetes discussion). More broadly, autologous HSCT is designated investigational for a number of non‑MS autoimmune and non‑hematologic indications listed in the Non‑covered Indications section.

Candidate Selection and Contraindications

Psychiatric illness that interferes with treatment adherence, a significant history of medical noncompliance, or unwillingness/inability to follow post‑transplant restrictions are stated contraindications. Additionally, high conditioning‑related risks (e.g., risk of life‑threatening marrow aplasia or sepsis) render HSCT unsuitable for routine use in some conditions; these factors should be documented during evaluation and prior authorization.

The policy repeats that psychiatric disease interfering with compliance, prior medical noncompliance, and inability or unwillingness to adhere to post‑transplant regimens are exclusionary considerations and should be documented when present.

Providers should document psychosocial and psychiatric stability; persistent or significant psychiatric disease that impairs adherence to the transplant pathway is a contraindication to coverage.

High conditioning‑related risks, including the potential for life‑threatening marrow aplasia, sepsis, and other severe complications, are considered contraindications in some settings and make HSCT unsuitable for routine use for certain non‑evidence‑based indications (e.g., Type 1 diabetes). Such risks must be weighed in eligibility determinations.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Pre-authorization and approved facility required

All bone marrow, peripheral stem cell, or other blood cell transplants must be pre‑authorized by Priority Health and performed at a Priority Health approved facility; requests for authorization must be submitted on the Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant prior authorization form.

Prior Authorization

UCBSCT covered only if allogeneic eligibility met

Umbilical cord blood stem cell transplant is covered only when the patient meets all eligibility requirements for an allogeneic stem cell transplant; non‑myeloablative allogeneic transplants may be covered when the transplant center prefers a reduced intensity regimen.

Prior Authorization

Prior authorization must justify aHSCT for Crohn's disease

Prior authorization should include evidence that the patient has refractory Crohn's disease after conventional medical and surgical therapies, documentation of risk counseling due to high rates of serious adverse events in recent trials, and that the transplant center has appropriate capabilities per EBMT/JACIE guidance.

Document failure of corticosteroids, immunosuppressants, biologics, and appropriate surgical management.
Include informed consent/risk discussion highlighting reported serious adverse events (eg, thrombotic microangiopathy, renal failure, pulmonary veno‑occlusive disease) and trial deaths.

Prior Authorization

Prior authorization should verify guideline-based AHSCT candidacy

Prior authorization is recommended to confirm AHSCT candidacy aligns with guideline‑based selection: relapsing forms with ongoing clinical or MRI inflammatory activity despite appropriate DMTs (especially high‑efficacy agents) or aggressive MS with rapid disability progression; document age, EDSS/ambulatory status, disease duration, MRI activity, and prior DMTs.

Document EDSS (ambulatory status), age (guidance cites <45–50 yrs), and disease duration (<10 years) when applicable.
Provide prior DMT history and evidence of breakthrough inflammatory activity (clinical relapses or Gd‑enhancing/new T2 lesions).

Note

No specific prior authorization rule stated

No explicit prior authorization requirements are specified in the referenced document excerpts.

Note

Prior authorization not specified (diagnosis codes only)

Prior authorization requirements are not specified in these excerpts; only diagnosis codes are provided to support medical necessity.

Documentation Required

Use listed ICD-10 codes to support prior authorization

Prior authorization and medical necessity determinations may be supported by the listed ICD‑10 codes for malignant immunoproliferative diseases, leukemias, multiple myeloma, and related hematologic neoplasms.

Examples listed include C88.8x, C90.00–C90.32, C91.00–C91.Z2, C92.00–C92.Z2 among others.

Documentation Required

Include an appropriate ICD-10 diagnosis on prior auth/claim

Prior authorization requests and claims should reference an appropriate supporting ICD‑10 diagnosis from the listed codes or code ranges (eg, hematologic malignancy and marrow disorder codes) when applicable to demonstrate medical necessity.

Include one of the listed diagnosis codes (examples: C90.00–C90.32; C91.00–C91.Z2; D46.0–D46.9; D56.1) on the request or claim.

Documentation Required

Include listed ICD-10 code ranges with prior authorization

Prior authorization and medical necessity requests should include one of the ICD‑10 codes or code ranges listed in the policy section to support the request.

Documentation Required

Use specified ICD-10 ranges as supporting diagnoses

The ICD‑10 codes and code ranges provided (including D46.0–D46.9, D56.1, D61.01–D61.9, D64.0–D64.4, D70.0, C96.Z/C96.9) may be used to support medical necessity for transplant‑related prior authorization requests.

Note

Diagnosis code list only — no auth rules stated

The ICD‑10 listings in these excerpts are diagnosis code lists only; no specific prior authorization rules are provided in these sections.

Prior Authorization

No prior authorization required for listed HPC/bone marrow CPTs (in‑network)

No prior authorization is required for in‑network providers for the listed hematopoietic progenitor cell and bone marrow CPT/HCPCS codes (see CPT list); out‑of‑network or other services may still require authorization per other policy sections.

Listed CPTs include 38204–38215, 38230, 38232, 38240–38243, and chimerism codes 81267–81268.
'* No prior authorization required for In‑Network providers' appears at the CPT code list.

Prior Authorization

In‑network exception: listed procedures not pre-authorized

The document states no prior authorization is required for in‑network providers for the listed hematopoietic progenitor cell and related transplantation procedure codes.

Billing Rule

Post-transplant immunosuppression coverage depends on drug benefits

Post‑transplant immunosuppressant drug therapy is covered when the member's group benefit includes outpatient prescription drug coverage; coverage depends on the member's benefit plan.

Documentation Required

Document prior therapy and response for MDS and MM

Coverage statements for MDS and multiple myeloma require documentation of prior therapy and response status; prior lines of therapy and response (eg, not responded, response to primary therapy) should be documented to support coverage.

For MDS: document lack of response to prior therapy and availability of an HLA‑matched donor.
For MM: document response to primary therapy or refractory/relapsed disease status.

Step Therapy

Document failure/intolerance of standard therapies before aHSCT

Candidates should have failed or been intolerant to standard therapies (including corticosteroids, immunosuppressants, biologics, and appropriate surgical management) before considering autologous HSCT for refractory conditions.

Step Therapy

MS: document failure of DMTs before AHSCT (per guidelines)

Guideline recommendations imply stepwise use of disease‑modifying therapies before AHSCT for MS: AHSCT is recommended for patients who have failed available DMTs (especially high‑efficacy agents) or who have aggressive disease where earlier intervention may be considered.

Document prior DMT history and failure of high‑efficacy agents when applicable.

Documentation Required

Perform and document transplant and social work evaluation

One transplant evaluation per transplant is covered and a formal social work evaluation is required to document psychosocial support and stability prior to transplant.

Include formal social work evaluation documenting family or alternative support network and emotional/psychiatric stability.

Documentation Required

Document organ function, tolerance, and informed consent

Clinical documentation must show the member meets medical necessity criteria including adequate major organ function, ability to tolerate transplant and immunosuppression, and informed consent regarding risks and potential late effects.

Document liver, cardiac, pulmonary, and renal function and predicted ability to tolerate procedure and post‑transplant regimen.
Obtain and document informed consent covering treatment‑related mortality and late effects.

Denial Risk

Missing or unsupported diagnosis codes risk denial

Claims or authorizations lacking an appropriate supporting ICD‑10 diagnosis from the listed codes (eg, leukemias, multiple myeloma, myelodysplastic syndromes, beta thalassemia) may not meet medical necessity documentation expectations and risk denial.

Denial Risk

Experimental/investigational transplants may be denied

Transplants that are experimental, investigational, or unproven (as listed in the policy) without approval under the referenced exception or clinical trials policies may be denied as not covered.

Examples listed as excluded include autologous SCT for Crohn's disease, stem cell therapies for erectile dysfunction, ALS, AMD, and type 1 diabetes.

Denial Risk

Safety concerns for Crohn's HSCT may lead to denial without risk justification

High rates of serious adverse events and treatment‑related deaths reported in a randomized trial of HSCT for refractory Crohn's disease create a safety‑triggered denial risk unless robust risk‑justifying documentation and center capability are provided.

The trial reported suspected unexpected serious adverse reactions in 46% of intervention patients, including thrombotic microangiopathy, renal failure, pulmonary veno‑occlusive disease, and deaths.

Billing Rule

Use transplant aftercare/status ICD-10 codes on claims

Use Z48.290 for encounter for aftercare following bone marrow transplant, Z94.81 for bone marrow transplant status, and Z94.89 for stem cells transplant status when documenting post‑transplant care.

Billing Rule

Report CPT/HCPCS procedure codes for HPC/transplant services

CPT/HCPCS procedure codes must be reported for HPC collection, processing, transplantation, and post‑transplant testing services; the policy lists the applicable CPT/HCPCS codes and indicates no prior authorization is required for in‑network providers for the listed codes.

Report applicable CPTs such as 38204–38215, 38230, 38232, 38240–38243 and chimerism codes 81267–81268 as appropriate.

Note

ICD-10 and CPT/HCPCS Codes

ICD-10 Codes that may support medical necessityICD-10

C40.00 - C40.92

Malignant neoplasm of bone and articular cartilage of limbs (Ewing's sarcoma)

ICD-10 Codes that may support medical necessityICD-10

C62.0 - C62.92	Malignant neoplasm of testis
C64.1 - C64.9	Malignant neoplasm of kidney, except renal pelvis (Wilms tumor)
C69.20 - C69.22	Malignant neoplasm of retina
C71.0 - C71.9	Malignant neoplasm of brain

ICD-10 Codes that may support medical necessity (lymphoma series)ICD-10

C81.00 - C81.99	Hodgkin lymphoma
C82.00 - C82.99	Follicular lymphoma
C83.00 - C83.99	Other non-Hodgkin lymphomas
C84.60 - C84.69	Anaplastic large cell lymphoma, ALK-positive
C84.70 - C84.7A	Anaplastic large cell lymphoma, ALK-negative
C84.A0 - C84.A9	Cutaneous T-cell lymphoma, unspecified
C84.Z0 - C84.Z9	Other Mature T/NK-cell lymphomas
C84.90 - C84.99	Mature T/NK-cell lymphomas, unspecified
C85.10 - C85.99	Other specified and unspecified types of non-Hodgkin lymphoma
C86.0 - C86.6	Other specified types of T/NK-cell lymphoma

ICD-10 Codes that may support medical necessityICD-10Covered

C83.00-C83.99	ICD-10 range listed in document
C84.60-C84.69	ICD-10 range listed in document
C84.70-C84.7A	ICD-10 range listed in document
C84.A0-C84.A9	ICD-10 range listed in document
C84.Z0-C84.Z9	ICD-10 range listed in document
C84.90-C84.99	ICD-10 range listed in document
C85.10-C85.99	ICD-10 range listed in document
C86.0-C86.6	ICD-10 range listed in document
C88.4x	ICD-10 code(s) listed in document
C88.8x	ICD-10 code(s) listed in document

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ICD-10 Codes that may support medical necessity (examples)ICD-10Covered

C84.90 - C84.99
C85.10 - C85.99
C86.0 - C86.6
C88.4x	lymphoid tissue [MALT-lymphoma]
C88.8x
C88.9
C90.00 - C90.32	Multiple myeloma and malignant plasma cell neoplasms
C91.00 - C91.Z2	Lymphoid leukemia
C92.00 - C92.Z2	Myeloid leukemia
C93.00 - C93.Z2	Monocytic leukemia

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Hematologic malignancy ICD-10 codesICD-10

C90.00 - C90.32	Multiple myeloma and malignant plasma cell neoplasms
C91.00 - C91.Z2	Lymphoid leukemia
C92.00 - C92.Z2	Myeloid leukemia
C93.00 - C93.Z2	Monocytic leukemia
C94.00 - C94.82	Other leukemias of specified cell type
C95.00 - C95.92	Leukemia of unspecified cell type
C96.9	Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
C96.Z	Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue

Non-malignant marrow disorder ICD-10 codesICD-10

D46.0 - D46.9	Myelodysplastic syndromes
D56.1	Beta thalassemia
D61.01 - D61.9	Other aplastic and bone marrow failure codes

ICD-10 Codes that may support medical necessityICD-10

C92.00-C92.Z2	Myeloid leukemias and related
C93.00-C93.Z2	Monocytic leukemia and related
C94.00-C94.82	Other leukemias of specified cell type
C95.00-C95.92	Leukemia of unspecified cell type
C96.9	Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
C96.Z	Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
D46.0-D46.9	Myelodysplastic syndromes
D56.1	Beta thalassemia
D61.01-D61.9	Aplastic and other bone marrow failure syndromes
D64.0-D64.4	Sideroblastic anemias and other specified anemias

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Hematologic / stem cell transplant–related diagnosesICD-10

C96.Z	Tissue, unspecified
C96.9	Malignant neoplasm, unspecified
D46.0 - D46.9	Myelodysplastic syndromes
D56.1	Beta thalassemia
D61.01 - D61.9	Aplastic and other anemias
D64.0 - D64.4	Anemias
D70.0	Congenital agranulocytosis

Primary immunodeficiency and metabolic/storage disordersICD-10

D81.0 - D81.7	Severe combined immunodeficiencies
D82.0	Wiskott-Aldrich syndrome
D84.0	Disorder involving the immune mechanism, unspecified
D89.9	Disorder involving the immune mechanism, unspecified
E70.330	Chediak-Higashi syndrome
E75.00 - E75.6	Disorders of sphingolipid metabolism and other lipid storage
E76.01 - E76.03	Mucopolysaccharidosis, type I
E85.0 - E85.9	Amyloidosis

Transplant aftercare / status codesICD-10Covered

Z48.290	Encounter for aftercare following bone marrow transplant
Z94.81	Bone marrow transplant status
Z94.89	Stem cells transplant status

Malignant neoplasm codes that may applyICD-10

C11.0 - C11.9	Malignant neoplasm of nasopharynx
C15.3 - C15.9	Malignant neoplasm of esophagus
C16.0 - C16.9	Malignant neoplasm of stomach
C18.0 - C20	Malignant neoplasm of colon/rectum
C23	Malignant neoplasm of gallbladder
C24.0 - C24.9	Malignant neoplasm of other and unspecified parts of biliary tract
C25.0 - C25.9	Malignant neoplasm of pancreas
C31.0 - C31.9	Malignant neoplasm of accessory sinuses
C34.00 - C34.92	Malignant neoplasm of bronchus and lung
C37	Malignant neoplasm of thymus

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ICD-10 codes referencedICD-10

C34.00 - C34.92	Malignant neoplasm of bronchus and lung
C37	Malignant neoplasm of thymus
C43.0 - C43.8	Malignant melanoma of skin
C49.0 - C49.A9	Malignant neoplasm of other connective and soft tissue
C50.011 - C50.929	Malignant neoplasm of breast
C53.0 - C53.9	Malignant neoplasm of cervix uteri
C54.0 - C55	Malignant neoplasm of uterus
C56.1 - C56.9	Malignant neoplasm of ovary
C64.1 - C64.9	Malignant neoplasm of kidney, except renal pelvis
C65.1 - C65.9	Malignant neoplasm of renal pelvis

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ICD-10 Codes that may applyICD-10

C54.0 - C55	Malignant neoplasm of the uterus
C56.1 - C56.9	Malignant neoplasm of ovary
C64.1 - C64.9	Malignant neoplasm of kidney, except renal pelvis
C65.1 - C65.9	Malignant neoplasm of renal pelvis
C71.0 - C71.9	Malignant neoplasm of brain
C73	Malignant neoplasm of thyroid gland
D00.0 - D00.2	Carcinoma in situ of oral cavity, esophagus and stomach
D03.0 - D03.9	Melanoma in situ
D06.0 - D06.9	Carcinoma in situ of cervix uteri
D45	Polycythemia vera

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ICD-10 Codes that may applyICD-10

C65.1 - C65.9	Malignant neoplasm of renal pelvis
C71.0 - C71.9	Malignant neoplasm of brain
C73	Malignant neoplasm of thyroid gland
D00.0 - D00.2	Carcinoma in situ of oral cavity, esophagus and stomach
D03.0 - D03.9	Melanoma in situ
D06.0 - D06.9	Carcinoma in situ of cervix uteri
D45	Polycythemia vera
D59.0	Drug-induced autoimmune hemolytic anemia
D59.1X	Other autoimmune hemolytic anemias
D65	Disseminated intravascular coagulation [defibrination syndrome]

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CPT/HCPCS CodesCPTCovered

38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor
38210	Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion
38211	Transplant preparation of hematopoietic progenitor cells; tumor cell depletion
38212	Transplant preparation of hematopoietic progenitor cells; red blood cell removal
38213	Transplant preparation of hematopoietic progenitor cells; platelet depletion

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Hematopoietic progenitor cell collection and preparation CPT codesCPTCovered

38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor
38210	Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion
38211	Transplant preparation of hematopoietic progenitor cells; tumor cell depletion
38212	Transplant preparation of hematopoietic progenitor cells; red blood cell removal
38213	Transplant preparation of hematopoietic progenitor cells; platelet depletion

Additional HPC, bone marrow, and chimerism CPT codesCPTCovered

38214	Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion
38215	Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer
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
38242	Allogeneic lymphocyte infusions
38243	Hematopoietic progenitor cell (HPC); HPC boost
81267	Chimerism (engraftment) analysis, post transplantation specimen; without cell selection

HLA typing, chimerism, and related laboratory CPT codesCPTCovered

81268	Chimerism (engraftment) analysis, post transplantation specimen; with cell selection, each cell type
81370	HLA Class I and II typing, low resolution
81371	HLA Class I and II typing, low resolution (verification typing)
81372	HLA Class I typing, low resolution; complete
81373	HLA Class I typing, low resolution; one locus, each
81374	HLA Class I typing, low resolution; one antigen equivalent, each
81375	HLA Class II typing, low resolution; DRB1/3/4/5 and DQB1
81376	HLA Class II typing, low resolution; one locus
81377	HLA Class II typing, low resolution; one locus, each
81378	HLA Class I and II typing, high resolution; HLA-A, -B, -C, and -DRB1

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HLA crossmatch and compatibility testing CPT codesCPTCovered

86821	HLA typing; lymphocyte culture, mixed (MLC)
86825	Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (e.g., using flow cytometry); first serum sample or dilution
86826	Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (e.g., using flow cytometry); each additional serum sample or dilution
86920	Compatibility test each unit; immediate spin technique
86921	Compatibility test each unit; incubation technique
86922	Compatibility test each unit; antiglobulin technique

Misc coding note (inv-65)

Coding window noteDocument lists extensive ICD-10 code ranges and lymphoma-series codes in the coding window; review claim diagnosis coding carefully.

Code groupingLymphoma and related hematologic neoplasm ranges (e.g., C83.00-C83.99, C84.60-C84.69) are presented together in this window.

Duplicate entries cautionThe coding window repeats certain code ranges across lines — verify the exact code(s) to bill to avoid duplication.

No numeric thresholds in this window (inv-66)

Numeric thresholds absentNo numeric thresholds (e.g., lab cutoffs, age ranges with numeric limits beyond those shown elsewhere) are provided in this coding window.

Use policy thresholds elsewhereRefer to disease-specific sections for numeric criteria (e.g., MS age <45) rather than this coding window.

Documentation implicationLack of numeric thresholds here means clinical judgment and referenced criteria must be documented in prior authorization requests.

Prior authorization exception (inv-67)

Prior authorization exceptionNo prior authorization required for In-Network providers for the listed hematopoietic progenitor cell and bone marrow CPT/HCPCS codes (e.g., 38204–38215, 38230, 38232, 38240–38243, 81267, 81268).

Applies to listed CPT codes onlyThe exception specifically refers to the CPT/HCPCS codes enumerated in the CPT/HCPCS Codes section; other services may still require authorization.

Verify network statusThis waiver applies only to in-network providers — out-of-network claims may be subject to standard prior authorization rules.

Evaluation, Center, and Documentation Requirements

Note

post-transplant aftercare / status coding (inv-166)

Aftercare encounter codeZ48.290 — Encounter for aftercare following bone marrow transplant.

Bone marrow transplant statusZ94.81 — Bone marrow transplant status (use to indicate transplant recipient status).

Stem cells transplant statusZ94.89 — Stem cells transplant status (other types of stem cell transplant status).

Chimerism (engraftment) analysis (inv-167)

Chimerism CPT codes81267 — Chimerism (engraftment) analysis, post-transplantation specimen (comparison to baseline); and 81268 — Chimerism analysis variant (with cell selection).

Service classificationChimerism analysis is listed as a post-transplant service in the CPT/HCPCS codes section.

Billing implicationReport the appropriate chimerism CPT code (81267 or 81268) for post-transplant engraftment testing as described in the policy coding list.

Definitions and Background

This policy governs hematopoietic stem cell and bone marrow transplantation — both autologous and allogeneic — for malignant and selected non‑malignant conditions. It establishes general candidacy requirements, condition‑specific coverage rules, authorization and facility requirements, and coding and documentation expectations to support medical necessity determinations.

Transplant types (inv-130)

Transplant types includedAllogeneic and autologous bone marrow, peripheral stem cell, or other blood cell transplants are covered for specified indications.

Conditioning intensity optionsPolicy includes both myeloablative and non-myeloablative (reduced intensity / mini-transplant) regimens.

Sources of stem cellsSources specified include autologous, syngeneic (identical twin), allogeneic (donor), and umbilical cord blood; peripheral blood collection via pheresis and bone marrow harvest are described.

Relapsing-remitting multiple sclerosis criteria (inv-131)

Required disease course and activityRelapsing-remitting MS (RRMS) with breakthrough inflammatory activity despite high-efficacy DMTs (either >=2 relapses in prior 12 months OR 1 relapse plus MRI gadolinium-enhancing lesion in prior 12 months).

Functional and age limitsEDSS score of 2.0–6.0 (ambulatory range), age less than 45 years, and disease duration less than 10 years are required criteria for AHSCT consideration.

Guideline alignment and documentationPrior authorization should confirm guideline-based candidacy including phenotype, MRI activity, prior DMT history, EDSS, age, disease duration, and recent disability progression when applicable.

Tandem Transplantation (inv-132)

Definition — Tandem transplantationTwo or more planned courses of high-dose chemotherapy and stem cell support (autologous or allogeneic), typically administered at intervals of two to six months contingent on recovery from prior toxicity.

Contrast with multiple cyclesMultiple cycles of high-dose chemotherapy with stem cell transplantation differ from tandem transplants by allowing more time between procedures for hematopoietic recovery.

Coverage implicationTandem transplants are addressed in disease-specific sections; verify policy rules for whether tandem strategies are covered or investigational for a given condition.

Responsive / Partial remission (inv-133)

Definition — Responsive / Partial remissionResponsive: tumor showing complete or partial remission. Partial remission: at least a 50% reduction in tumor burden.

Refractory vs relapseRefractory disease = failure to attain complete or partial response; relapse = tumor recurrence after prior complete remission.

Use in eligibility assessmentsTerms used to define transplant candidacy and timing (e.g., relapsed, refractory, partial response) in disease-specific coverage rules.

Sources of Stem Cells (inv-134)

Sources of stem cells — typesAutologous (patient), syngeneic (identical twin), allogeneic (donor), and umbilical cord blood (neonatal source) are listed as stem cell sources.

Peripheral blood collectionPeripheral stem cells are commonly harvested via one or more pheresis procedures; growth factors and prior chemotherapy may be used to mobilize cells.

Allogeneic advantagesAllogeneic grafts avoid tumor contamination and may provide graft-versus-tumor effects; cord blood cells are antigenically naïve with lower rejection/GVHD risk.

Autologous hematopoietic stem cell transplantation (aHSCT) (inv-135)

Procedure summary — aHSCTAutologous hematopoietic stem cell transplantation harvests the patient's own stem cells, administers immune-ablative or immunosuppressive conditioning, and reinfuses cells to reconstitute the immune system for disease control.

Indications in autoimmune diseaseAHSCT may be used for MS with inflammatory activity not responsive to DMTs; EBMT and other guidelines recommend careful patient selection and center expertise.

Risks and informed consentHSCT is associated with greater short-term risks (including treatment-related mortality) and long-term late effects; risks increase with age and comorbidity and require individualized decision-making and informed consent.

Autologous hematopoietic stem cell transplantation (AHSCT) (inv-136)

AHSCT for MS — therapeutic aimAHSCT ablates the aberrant immune system and reconstitutes a new immune system from the patient’s harvested stem cells to reduce inflammatory disease activity.

Evidence baseRandomized and guideline evidence (e.g., Burt et al., 2019 trial and EBMT recommendations) support AHSCT in selected MS patients with inflammatory disease activity unresponsive to DMTs.

Candidate profileOptimal candidates are younger, ambulatory patients with active inflammatory disease despite high-efficacy DMTs; baseline EDSS, MRI activity, prior DMT history, age, and disease duration should be documented.

NCCN guideline references for lymphoma/myeloma/related conditions (inv-137)

NCCN referencesNCCN guideline citations are referenced for lymphoma and myeloma-related conditions and used to inform disease-specific coverage rules.

Guideline-based decision supportProviders should align transplant indications with current guideline recommendations (NCCN, EBMT, ASBMT) when applicable.

Document guideline concordancePrior authorization requests should document how the proposed transplant aligns with cited guideline recommendations.

MALT-lymphoma (inv-138)

MALT-lymphoma definition referenceExtranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) is listed among ICD-10 ranges and referenced conditions.

Coding implicationUse the documented ICD-10 ranges (e.g., C88.4x) when claiming transplant-related services for MALT-lymphoma indications.

Coverage contextMALT-lymphoma appears in the malignant immunoproliferative disease group used to support transplant medical necessity determinations.

Multiple myeloma and leukemias (inv-140)

Multiple myeloma and leukemia code rangesICD-10 ranges such as C90.00-C90.32 (multiple myeloma) and C91.00-C95.92 (various leukemias) are listed to support medical necessity for transplant services.

Use in claims/supporting documentationInclude an appropriate ICD-10 code from the listed ranges on claims and prior authorization requests to support medical necessity.

Related conditions includedThe coding list groups multiple hematologic neoplasms together for transplant eligibility considerations (e.g., C92.*, C93.*, C94.*).

Myelodysplastic syndromes (inv-141)

Myelodysplastic syndromes codesD46.0-D46.9 is listed as the ICD-10 range representing myelodysplastic syndromes used to support transplant indications.

Related marrow disordersAplastic anemias and other bone marrow failure syndromes (D61.01-D61.9), sideroblastic anemias (D64.0-D64.4), and beta thalassemia (D56.1) are included among supportive diagnoses.

Coverage implicationsAllogeneic transplant coverage for MDS requires intermediate/high-risk disease and lack of response to prior therapy with an available HLA-matched donor.

Beta thalassemia (inv-142)

Beta thalassemia codeD56.1 is specifically listed for beta thalassemia as a non-malignant indication that may support transplant consideration.

Clinical relevanceBeta thalassemia is included among hematologic disorders where transplant may be indicated under specified criteria.

Coding useUse D56.1 on claims or prior authorization documentation when beta thalassemia is the supporting diagnosis for transplant services.

Z48.290 / Z94.81 / Z94.89 (inv-144)

Z-codes for post-transplant statusZ48.290 (aftercare following bone marrow transplant), Z94.81 (bone marrow transplant status), and Z94.89 (stem cells transplant status) are specified for post-transplant coding.

Chimerism testing codesCPT codes 81267 and 81268 for chimerism (engraftment) analysis are listed in the CPT/HCPCS coding section as post-transplant services.

HPC/CPT grouping — no prior auth for in-networkHematopoietic progenitor cell collection/processing and related transplant CPTs (38204–38215, 38230, 38232, 38240–38243) are enumerated in the policy; in-network providers have no prior authorization requirement for these listed codes.