Modifiedpriority healthPolicy N/A

Stem Cell or Bone Marrow Transplantation

Policy governing coverage, prior authorization, and medical necessity criteria for autologous and allogeneic bone marrow, peripheral stem cell, and other blood cell transplants for Priority Health members.

Policy Summary

Payerpriority health

PolicyStem Cell or Bone Marrow Transplantation

Policy CodePolicy N/A

Change TypeMaterial clinical coverage addition

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain Priority Health prior authorization using the Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant form and submit documentation demonstrating medical necessity (including transplant evaluation, social work evaluation, prior therapies, and organ function).

SourceLink

POLICY UPDATE CHANGES

Autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis may be considered medically necessary when criteria are met.

New Related policies section

1 yearpost-transplant follow-up

18-45MS HSCT age window

EDSS 2.0-6.0MS EDSS window

max 3MM tandem limit

HLA-matched

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.

Allogeneic donor requirement

manyAutologous exclusions

Coverage Criteria and Indications

General Coverage Criteria

Covered when ALL of the following are met

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

See transplant-specific sections for additional disease-specific criteria; one transplant evaluation per transplant is covered.

Exclusion Criteria

Not covered when ANY of the following are present

Behavioral and compliance exclusions: Persistent or active substance or alcohol abuse; psychiatric disease that would interfere 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.

These conditions typically trigger non-coverage unless an exception applies under policy #91117 or applicable clinical trials policies.

Autologous HSCT for Multiple Sclerosis

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

MS HSCT criteria

Evidence of breakthrough disease: Two or more clinical relapses within the prior 12 months OR one relapse plus MRI gadolinium‑enhancing lesion(s) at a separate time within the prior 12 months.12 months

Non-malignant Conditions (Allogeneic)

Allogeneic transplants may be considered medically necessary for selected non-malignant conditions when disease-specific criteria are met

Selected non-malignant indications: Includes sickle cell anemia in children/young adults with prior stroke or high risk for stroke/end-organ damage with an HLA‑identical donor; severe or very severe aplastic anemia meeting laboratory thresholds (platelets <20 x10^9/L, granulocytes <0.5 x10^9/L, corrected reticulocytes <1%) after failed ATG therapy; homozygous beta‑thalassemia (thalassemia major); Wiskott‑Aldrich syndrome; severe combined immunodeficiencies; Chediak‑Higashi syndrome; infantile malignant osteopetrosis; selected mucopolysaccharidoses or mucolipidoses in neurologically intact patients; Kostmann's syndrome; leukocyte adhesion deficiencies; X‑linked lymphoproliferative syndrome.aplastic anemia lab thresholds as stated

UCBSCT covered only when patient meets all eligibility requirements for allogeneic SCT.

Pediatric Solid Tumors / Neuroblastoma

Covered pediatric indications

Childhood solid tumors: High‑dose chemotherapy followed by autologous hematopoietic stem‑cell transplantation is covered for relapsed Wilms' tumor, metastatic non‑CNS retinoblastoma, and relapsed or progressive Ewing family tumors.

High‑risk neuroblastoma: Autologous stem‑cell transplantation is covered for high‑risk neuroblastoma; a maximum of three tandem autologous HSCTs are covered. Allogeneic SCT from an appropriately‑matched HLA donor is covered when the individual is not a candidate for autologous HSCT.max 3 tandem HSCTs

Malignancy-specific Coverage

Coverage statements by malignancy

Adult solid tumors: Autologous or allogeneic HSCT (ablative or non‑myeloablative) for the listed adult solid tumors (eg, bile duct, breast, CNS tumors, colon, epithelial ovarian, esophagus, gallbladder, pancreas, lung, melanoma, kidney, etc.) is considered experimental and investigational and not covered.

See 'Not Covered Indications' and solid tumors section.

Germ cell tumors: Single or tandem autologous SCT is covered for relapsed or refractory testicular and ovarian germ cell tumors; autologous SCT as front‑line therapy and allogeneic SCT are investigational; SCT is not covered for epithelial ovarian cancer.

Hodgkin lymphoma: 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 SCT investigational.

Non‑Hodgkin lymphoma:

Myelofibrosis

Covered indications and exclusions for myelofibrosis:

Myelofibrosis - allogeneic covered: Allogeneic (ablative or non‑myeloablative) stem cell transplantation is a covered benefit for individuals who are transfusion dependent, resistant to conservative therapy, or who have intermediate or high‑risk myelofibrosis.

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

Myelofibrosis - autologous investigational: Autologous stem cell transplantation is considered experimental and investigational for myelofibrosis and is not a covered benefit.

Myelodysplastic Syndrome (MDS)

Covered and investigational uses for MDS:

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

Repeat allogeneic SCT is covered for primary graft failure or failure to engraft; repeat allogeneic for relapse is considered experimental.

MDS - autologous investigational: Autologous stem cell transplantation is considered experimental and investigational for MDS because effectiveness has not been established.

Acute Myelogenous Leukemia (AML)

Covered uses, repeats, and investigational statements for AML:

AML - transplant covered: Autologous or allogeneic stem cell transplant (ablative or non‑myeloablative) is covered for AML in first complete remission, primary refractory AML, or relapsed AML.

AML - repeat transplant covered for graft failure/relapse: Repeat autologous or allogeneic hematopoietic cell transplantation is covered when the first transplant was unsuccessful due to primary graft failure or failure to engraft or for persons who have relapsed after a prior SCT.

A repeat transplant for persistent or progressive disease is considered investigational.

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

Acute Lymphocytic Leukemia (ALL)

Coverage for ALL including mini‑allograft and repeat transplant timing:

ALL - allogeneic covered: Allogeneic stem cell transplantation is covered for treatment of ALL, including primary refractory ALL, except for refractory relapse unresponsive to ≥3 months of adequate chemotherapy.

ALL - non‑myeloablative covered: Non‑myeloablative allogeneic transplantation (mini‑allograft) is covered for members with no persistent disease who meet selection criteria; persons with persistent disease are not candidates for mini‑allograft.

ALL - second myeloablative allogeneic 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.>6 months

ALL - autologous covered when no donor:

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

CLL/SLL - allogeneic covered: Allogeneic stem‑cell transplantation is covered for CLL not responsive to standard therapy.

CLL/SLL - autologous covered in remission: Autologous stem cell transplantation is covered for CLL in an individual in complete or good partial remission.

Multiple Myeloma (MM)

Autologous and allogeneic transplant coverage for MM and repeat/tandem rules:

MM - autologous initial covered: Autologous stem‑cell transplantation is covered for active (symptomatic) multiple myeloma after response to primary therapy or for refractory disease with relapse or progressive disease.

MM - second autologous may be necessary: A second course of autologous hematopoietic cell transplantation may be considered medically necessary for responsive MM that has relapsed after a durable complete or partial remission following an autologous transplantation.

MM - third autologous covered: A third autologous SCT for treatment of active MM is a covered benefit for individuals with progressive disease following a previous autologous HSCT.

MM - tandem/autologous->allogeneic covered if within 6 months: Tandem autologous transplants or autologous followed by allogeneic transplant (haploidentical to fully matched related donor or well‑matched unrelated donor meeting NMDP criteria) are medically necessary if the planned first and second transplants occur within a 6‑month period.

Amyloidosis and POEMS

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

Amyloidosis - certain uses investigational: Second autologous SCT for recurrent/refractory amyloidosis, tandem autologous SCT, and allogeneic SCT are considered experimental and not covered for amyloidosis.

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

Nonmyeloablative Allogeneic SCT - eligible conditions

Nonmyeloablative allogeneic SCT may be considered medically necessary when patient otherwise meets selection criteria for high‑dose chemotherapy and allogeneic SCT for the following:

Nonmyeloablative - listed conditions: May be medically necessary for listed malignancies and disorders including non‑Hodgkin lymphoma, Hodgkin disease, myelodysplastic syndromes/MDS, AML, CML, ALL, CLL, multiple myeloma, aplastic anemia, myelofibrosis, neuroblastoma, sickle cell anemia, and thalassemia major.

Use in patients who do not meet criteria due to age or comorbidities, or for other malignancies/solid tumors, is investigational.

Tandem transplants

General stance on tandem transplants

Tandem - conditional coverage: Tandem transplants may be a covered benefit for specific conditions if noted as covered in the applicable section; for other conditions tandem transplants are considered experimental and investigational.

Examples: tandem neuroblastoma (max 3) covered; tandem strategies in NHL, AML, ALL often investigational per disease sections.

Other non-covered indications (experimental/unproven)

Non-covered list: 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 or 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 are considered experimental/unproven and excluded from coverage.

Specific CPT/HCPCS codes for certain intramuscular autologous bone marrow cell therapies are listed as Not Covered.

Repeat transplant rules (general)

Policy on repeat transplants across conditions:

Repeat transplant - graft failure/failed engraftment covered: Repeat allogeneic or autologous transplantation (ablative or non‑myeloablative) is covered when the prior transplant was unsuccessful due to primary graft failure or failure to engraft.

Applies across multiple disease‑specific sections; documentation of graft failure required.

Repeat transplant for relapse often investigational: Repeat transplantation for disease relapse is considered investigational for certain conditions (eg, repeat allogeneic SCT for MDS relapse, repeat autologous for some indications) as specified in condition‑specific sections.

See disease‑specific coverage statements for exceptions where repeat transplant is covered (eg relapse >6 months after first allogeneic SCT in ALL).

Coverage considerations and evidence-based candidate selection

Coverage considerations and candidate selection criteria emerging from the evidence and guideline statements

aHSCT for refractory Crohn's disease (evidence summary): Consideration for autologous HSCT in Crohn's disease may be limited to patients refractory to conventional medical and surgical therapies; systematic reviews/meta‑analyses show efficacy on CDAI and fistula outcomes but randomized trial(s) reported high rates of serious adverse events including treatment‑related deaths with immune‑ablative regimens.

Safety concerns necessitate careful candidate selection and informed‑consent documentation.

AHSCT for MS (guideline‑aligned candidates): Guidelines (EBMT/ASTCT/NMSS) recommend AHSCT for patients with inflammatory MS activity despite DMTs, preferably younger and ambulatory; candidates commonly have failed high‑efficacy DMTs or have aggressive disease; documentation of relapses, MRI activity, EDSS and prior therapies is recommended.EDSS ≤5.5 favored; age <45-50 preferred; disease duration <10 years preferred

Prior authorization requests should demonstrate refractory disease and guideline‑consistent selection.

AHSCT for Multiple Sclerosis

Covered when ALL of the following are met (for AHSCT in multiple sclerosis, based on guidelines and trial evidence):

MS AHSCT candidate criteria: 1) Diagnosis of relapsing MS (RRMS) or SPMS/PPMS with superimposed inflammatory activity; 2) Evidence of ongoing clinical relapses or MRI lesion activity despite treatment with available DMTs (especially high‑efficacy DMTs) OR aggressive disease with rapid disability accumulation; 3) Age typically younger than 45–50 years (preferred); 4) Disease duration less than 10 years (preferred); 5) Ambulatory or EDSS 5.5 or less is favored; 6) Treatment provided at an accredited transplant center with multidisciplinary evaluation and documented prior therapies and evaluations.EDSS ≤5.5 favored; age <45-50; disease duration <10 years

Derived from ASTCT/EBMT/NMSS position statements and systematic reviews; individualization recommended.

Cell-based therapy for ALS/MND

Coverage stance for ALS/MND (cell therapy):

ALS/MND cell therapy: Evidence for bone marrow–derived mesenchymal stem cell (BM‑MSC) therapy in ALS/MND is low‑certainty; small RCTs show modest differences in ALSFRS‑R and no clear survival benefit. Cell‑based therapy for ALS/MND is considered investigational and appropriate only in research settings.ALSFRS‑R change of ≥4 points considered clinically important

Uncertainties remain about effects on strength, progression, and survival.

Stem cell therapy for Type 1 Diabetes Mellitus

Coverage stance for Type 1 Diabetes:

Stem cell therapy for T1DM: Stem cell therapies (including MSCs and HSCT) for type 1 diabetes mellitus remain investigational; some meta‑analyses report improvements in glycemic markers and insulin requirements but HSCT is unlikely to be useful clinically because conditioning imparts significant life‑threatening risks.

Consider only in research settings; UpToDate notes risks of conditioning limit HSCT utility for T1DM.

Allogeneic HSCT for post-ET/post-PV myelofibrosis

Coverage stance for post‑ET and post‑PV myelofibrosis:

Allogeneic HSCT for post‑ET/post‑PV MF: Allogeneic HSCT is potentially curative and may be considered for secondary myelofibrosis (post‑ET/post‑PV) acknowledging substantial non‑relapse mortality and donor/source effects; patient selection and donor choice (related vs UCB) affect outcomes and require individualized assessment.

Registry data report 1‑year non‑relapse mortality 27–35% and 4‑year OS 46–65%; UCB associated with lower neutrophil recovery and worse OS in some series.

Cell therapy for RDEB

Coverage stance for Recessive Dystrophic Epidermolysis Bullosa (RDEB):

Allogeneic BMT and MSC therapy for RDEB: Allogeneic bone marrow transplantation may provide clinical benefit for severe RDEB but carries high risks (graft failure, sepsis, GVHD, transplant‑related deaths); BM‑MSC therapies show favorable wound‑healing signals in small studies but long‑term outcomes and safety require further study. Consider investigational or risk‑stratified use at specialized centers.

Systematic review: 96.4% had improved wound healing; transplant‑related deaths reported (3/55).

Evidence summaries / Informational coverage considerations

Evidence summaries and clinical conclusions in this excerpt (informational; no explicit payer criteria stated in these chunks):

EB evidence summary: Systematic reviews for epidermolysis bullosa and related cell therapies report high rates of improved wound healing but also serious adverse events including graft failure, sepsis (reported deaths), GVHD and renal insufficiency; allogeneic BMT is high‑risk with potential benefit while BM‑MSC may improve safety but requires further study.

Informational summary of evidence; not prescriptive coverage criteria.

RP MSC evidence: Systematic review/meta‑analysis of MSCs in retinitis pigmentosa showed short‑term improvements in BCVA and retinal function with benefits sustained up to 12 months in many studies; long‑term efficacy uncertain and additional RCTs needed.up to 12 months

Informational only.

TTP summary: TTP is life‑threatening and managed with plasma therapies; stem cell therapy has been proposed but lacks sufficient evidence due to rarity of condition.

Experimental, investigational, or unproven bone marrow, peripheral stem cell, or other blood cell transplants are not covered benefits unless an exception is granted under Priority Health policy #91117 or the procedure is part of an applicable clinical trial per policies #91448 or #91606. All transplants must be preauthorized by Priority Health and performed at a Priority Health–approved facility; requests should be submitted on the designated prior authorization form. (See prior authorization and provider documentation requirements.)

The policy lists specific exclusions for amyloidosis and other conditions. For amyloidosis, autologous stem cell support for primary systemic (AL) amyloidosis is covered, but a second autologous SCT for recurrent or refractory amyloidosis, tandem autologous SCT, and allogeneic SCT are considered experimental and not covered. Additionally, the policy explicitly excludes a variety of other experimental or unproven indications including autologous SCT for Crohn's disease and several non‑transplant cell therapies (see Not Covered Indications).

Allogeneic hematopoietic stem cell transplantation (allo‑HSCT) is a more complex procedure that requires a suitable donor and carries higher short‑term and long‑term risks compared with autologous HSCT. Autologous HSCT is the procedure most commonly used for severe autoimmune diseases because it avoids donor immunologic complications; decisions regarding allo‑HSCT versus autologous approaches must be individualized and delivered at experienced transplant centers given the increased peri‑procedural risk and potential for significant late effects.

Autologous HSCT for type 1 diabetes mellitus is considered unlikely to be useful for routine clinical care because the conditioning regimens carry significant life‑threatening risks (for example, bone marrow aplasia and sepsis). Therefore, autologous HSCT for type 1 diabetes remains investigational and appropriate only in a research or clinical‑trial setting.

The document provides an extensive list of Not Covered Indications by ICD‑10 code. These include a broad set of adult solid tumors, certain autoimmune and inflammatory disorders, metabolic and retinal diseases (for example, type I diabetes, Crohn's disease, retinitis pigmentosa, epidermolysis bullosa), and other diagnoses for which transplantation or stem cell procedures are excluded from coverage when submitted for these primary diagnoses.

The policy states that autologous or allogeneic stem cell transplantation is considered experimental, investigational, or unproven (and therefore not covered) for many indications, notably a wide range of adult solid tumors and numerous non‑oncologic conditions. Specific examples called out as not medically necessary include autologous SCT for Crohn's disease and autologous/allogeneic SCT for listed adult solid tumors where effectiveness has not been established.

The policy designates numerous uses of stem cell transplantation as investigational and not covered. Examples include autologous SCT for myelofibrosis and myelodysplastic syndromes (MDS) where autologous approaches are considered experimental; high‑dose autologous support for chronic myelogenous leukemia is investigational; tandem SCT for AML and ALL is investigational; and a list of non‑oncologic and emerging indications are explicitly excluded.

The policy identifies non‑transplant stem cell therapies for several non‑covered indications, including erectile dysfunction and various cardiac conditions (e.g., coronary artery disease, myocardial infarction, heart failure, angina). Systematic reviews and guideline statements cited in the document describe promising early data for some approaches but note insufficient high‑quality evidence, lack of standardized protocols, and thus an investigational status for these applications.

Cell‑based therapies for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND) and autologous HSCT for type 1 diabetes remain unsupported by high‑certainty evidence for routine clinical use. The available randomized and controlled studies are small and provide low‑certainty estimates of benefit; as a result these therapies are considered investigational and should be used only in research settings.

The policy lists specific procedure codes designated as not covered for intramuscular autologous bone marrow cell therapy: CPT codes 0263T, 0264T, and 0265T. It also references HCPCS/CPT code S2150 as a comprehensive code related to bone marrow or blood‑derived stem cell harvesting/transplantation that is listed in the document and referenced in coding exclusions.

Candidate Selection and Eligibility

General Candidate Requirements

Candidate must meet general and disease-specific criteria

Overall candidate prerequisites: Adequate major organ function; ability to tolerate procedure and immunosuppression; documented social support and formal social work evaluation; absence of active substance abuse, uncontrolled psychiatric disease, or significant medical noncompliance; ability to understand risks and participate in follow‑up.

Selection depends on disease‑specific criteria and availability of appropriately matched donor for allogeneic procedures.

CANDIDATE CRITERIA

Selection depends on disease‑specific criteria and availability of appropriately matched donor; nonmyeloablative transplants may be used when indicated

Donor requirement for allogeneic procedures: For many allogeneic indications (eg intermediate‑ or high‑risk MDS, selected non‑malignant disorders), coverage requires an available appropriately‑matched HLA donor; umbilical cord blood transplantation is covered only when the patient meets allogeneic SCT selection criteria.

Contraindications and Evaluation Requirements

Prior Authorization

Prior Authorization and Plan-Dependent Coverage

Prior authorization is required for autologous hematopoietic stem cell transplant (aHSCT) and related stem cell transplantation (SCT) services in accordance with the member's specific plan terms. Providers must submit a prior authorization request demonstrating medical necessity and include required clinical documentation. Prior authorization requirements, criteria, and documentation expectations are plan-dependent — check the member's Benefit Plan for coverage limits, benefit exclusion language, and any plan-specific authorization procedures.

Prior authorization required for aHSCT and related SCT services (plan-dependent).
Prior authorization must demonstrate medical necessity per Priority Health procedures and provider manual.
Coverage for SCT (including umbilical cord blood transplant) is conditional on the member's plan terms and any applicable benefit limits or exclusions.

Prior Authorization

Prior Authorization Criteria for AHSCT in Multiple Sclerosis

Prior authorization criteria for aHSCT when used for Multiple Sclerosis (MS) must be met and documented. AHSCT is considered only for MS patients with active inflammatory disease who have inadequate response, intolerance, or contraindication to appropriate, guideline-directed disease-modifying therapies (DMTs). Optimal candidates are typically younger, ambulatory patients with relapsing disease activity (e.g., RRMS) and evidence of inflammatory activity on MRI or clinical relapses.

Provider Requirements and Authorization

Prior Authorization

Preauthorization required; must be at Priority Health–approved facility

All bone marrow, peripheral stem cell, or other blood cell transplants must be preauthorized by Priority Health and be performed at a Priority Health–approved facility; requests must use the designated prior authorization form.

Transplants require preauthorization by Priority Health.
Transplants must be performed at Priority Health approved facilities.
Use the Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant prior authorization form.

Prior Authorization

Submit prior authorization with medical‑necessity documentation

Providers must submit prior authorization when required and include documentation demonstrating that the service is medically necessary in accordance with the Priority Health Provider Manual.

Submit medical necessity evidence as part of prior authorization requests.
Refer to the Provider Manual for submission details.

Billing and Diagnosis Codes

Covered/Applicable ICD-10 Codes (not exhaustive)ICD-10

C40.00 - C40.92	Malignant neoplasm of bone and articular cartilage of limbs
C56.1 - C56.9	Malignant neoplasm of ovary
C62.0 - C62.92	Malignant neoplasm of testis
C64.1 - C64.9	Malignant neoplasm of kidney, except renal pelvis
C69.20 - C69.22	Malignant neoplasm of retina
C71.0 - C71.9	Malignant neoplasm of brain
C81.00 - C81.99	Hodgkin lymphoma
C82.00 - C82.99	Follicular lymphoma
C83.00 - C83.99	Small cell B-cell lymphoma
C84.60 - C84.69	Anaplastic large cell lymphoma, ALK-positive

1–10 of 45

1/5

Not Covered ICD-10 Codes (listed in document)ICD-10Not Covered

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 the colon
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

1–10 of 54

1/6

CPT/HCPCS Codes (included and Not Covered codes)mixed

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
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing
38210	Transplant preparation of hematopoietic progenitor cells; specific cell depletion, T-cell depletion
38211	Transplant preparation; tumor cell depletion
38212	Transplant preparation; red blood cell removal
38213	Transplant preparation; platelet depletion

1–10 of 55

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Duration of follow-up for MSC efficacy in RP

Duration of sustained benefitMost MSC studies in retinitis pigmentosa report sustained improvements up to 12 months.

Evidence baseSystematic review/meta-analysis included 11 studies with 355 RP patients showing short-term BCVA and retinal function improvements.

Delivery methodsSubretinal and suprachoroidal delivery were associated with better outcomes than systemic infusion in reviewed studies.

Safety profileAdverse effects were minimal across studies, most commonly transient inflammation.

Post-Transplant Coverage and Follow-up

Follow-up care, facility and professional services; post-transplant immunosuppressant drug therapy

Covered services (first year)Follow-up care, facility and professional services are included in an approved transplant benefit for one year post‑transplant.

Immunosuppressant drugsPost‑transplant immunosuppressant drug therapy is covered if the employer group has outpatient prescription drug coverage.

Pre‑transplant componentsAn approved transplant includes pre‑transplant evaluation and one evaluation per transplant; transplant care, facility, and professional fees are included.

Long-term follow-up services and testing

Coverage beyond 1 year (contracted centers)Follow‑up care beyond one year is covered at contracted transplant facilities.

Non‑contracted facilities

Definitions and Background

Background: Bone marrow and hematopoietic stem cell transplantation (autologous and allogeneic) are established therapies for a range of malignant and non‑malignant hematologic conditions and certain pediatric solid tumors. Candidate selection requires adequate major organ function, documented psychosocial support, and donor matching for many allogeneic procedures. Transplants carry higher short‑term risks and potential long‑term late effects than most standard therapies and are delivered at accredited, experienced centers; follow‑up care at the transplant facility is covered for one year post‑transplant.

Allogeneic — Definition

DefinitionAllogeneic transplant: stem cells are obtained from a donor (related, unrelated, or umbilical cord blood) and infused into the recipient.

Donor matchingAllogeneic procedures often require HLA matching and carry risks such as graft‑versus‑host disease and higher treatment‑related mortality compared with autologous transplants.

IndicationsAllogeneic transplants are used for selected malignant and non‑malignant conditions (eg, MDS, aplastic anemia, hemoglobinopathies) when disease‑specific criteria are met.

Center and Facility Requirements

Prior Authorization

Transplants must be performed at Priority Health approved facilities

Transplants must be performed at a Priority Health–approved facility; referrals should be directed to Priority Health network or contracted transplant centers as stated in the Provider Manual.

Perform transplants at Priority Health approved facilities.
Direct referrals to Priority Health network or contracted transplant centers.

Policy Changes and Revision History

2025-06-01effective_dateLatest

Policy modified to add an explicit coverage statement for autologous hematopoietic stem cell transplantation (AHSCT) for multiple sclerosis with specified candidate criteria (age, EDSS, disease duration, and breakthrough inflammatory activity).

2024-07-01administrative_update

Related policies section added (references to policies #91117, #91448, and #91606 noted).

Note

Policy Summary

Payerpriority health

PolicyStem Cell or Bone Marrow Transplantation

Policy CodePolicy N/A

Change TypeMaterial clinical coverage addition

Effective DateJun 1, 2025

Next Review DateN/A

SourceLink

On This Page

Autologous or allogeneic SCT is covered for relapsed or primary refractory NHL; high‑dose chemotherapy with stem‑cell support as initial therapy is investigational; non‑myeloablative allogeneic HCT may be covered when preferred by transplant center; tandem strategies investigational.

Leukemias and MDS: Allogeneic (ablative and non‑myeloablative) transplants are covered for AML, ALL, CML, intermediate/high‑risk MDS, and CLL as specified in condition sections; autologous SCT is covered or investigational depending on disease and donor availability (see disease‑specific rules).

Repeat transplants may be covered for graft failure; repeat for relapse often investigational per disease-specific rules.

Multiple myeloma: Autologous SCT is covered for active symptomatic MM after response to primary therapy or for relapse/refractory disease; second or third autologous SCTs may be covered in specified scenarios; tandem/autologous→allogeneic strategies medically necessary if planned within a 6‑month period; allogeneic SCT covered after autologous relapse from appropriate HLA‑matched donor.

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

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

MM - allogeneic covered after autologous relapse: Allogeneic SCT from an appropriately‑matched HLA donor is covered for active MM with progressive disease following autologous HSCT.

Other stem cell therapies investigational:

Cell‑based therapies for indications such as erectile dysfunction, cardiac disease, ALS, AMD and type 1 diabetes show mixed or low‑certainty evidence and are considered investigational outside clinical trials.

Examples and evidence summaries cited in policy.

Donor/source choice affects outcomes (eg UCB associated with lower neutrophil recovery).

Candidate selection (excerpt)

Selection criteria referenced in guidelines and evidence summaries:

MS candidate for AHSCT: Patient with MS demonstrating inflammatory disease activity (clinical relapses or MRI activity) and inadequate response or intolerance to approved DMTs; preferably younger and ambulatory with documented EDSS and prior treatments.

Guideline‑aligned selection recommended and used for prior authorization documentation.

Crohn's disease candidate for aHSCT: Patient with Crohn's disease refractory to standard medical and surgical therapies may be considered only after weighing substantial short‑term risks; informed‑consent and safety documentation required.

Randomized evidence shows serious adverse events with immune‑ablative regimens.

AHSCT candidate criteria (MS)

MS candidate selection per guideline summaries:

MS AHSCT candidate nodes: Candidates are those with relapsing inflammatory disease activity despite one or more lines of approved DMTs (especially high‑efficacy agents) or with aggressive disease; recommended characteristics include age typically <45–50 years, disease duration <10 years, and ambulatory status with EDSS ≤5.5 preferred.EDSS ≤5.5; age <45-50; disease duration <10 yrs

Derived from EBMT/ASTCT/NMSS recommendations; individualization and documentation required.

Priority Health does not cover bone marrow or stem cell transplantation when there is persistent or active substance or alcohol abuse or when a member has a psychiatric disorder that would interfere with compliance with transplant requirements. These behavioral and compliance‑related exclusions also include a significant history of medical noncompliance or unwillingness/inability to adhere to post‑transplant restrictions and regimens; such conditions trigger non‑coverage unless an exception is granted under the experimental/unproven exceptions policy.

Advanced age, more advanced disease, and the presence of significant comorbid conditions increase the risk of transplant‑related complications, including treatment‑related mortality and late effects. These factors may contraindicate hematopoietic stem cell transplantation or influence the decision to pursue a reduced‑intensity/nonmyeloablative approach and should be considered during candidate selection and prior authorization review.

AHSCT for MS requires documented failure, contraindication, or intolerance to high-efficacy DMTs consistent with specialty society guidance.
Evidence of active inflammatory disease (clinical relapses or MRI activity) must be documented.
Candidates should be clinically appropriate (typically younger, ambulatory) with an assessment that benefits outweigh risks.

Billing Rule

Prior Authorization — Procedure Codes and Submission Note

Prior authorization status applies to specific procedure and billing codes used for aHSCT and related SCT services. Verify code-level authorization requirements before claim submission to avoid denials. Authorization determinations do not guarantee payment — adjudication remains subject to plan benefit terms.

Providers must request prior authorization for the CPT/HCPCS codes associated with harvest, conditioning, infusion, and related inpatient/outpatient services for SCT.
Prior authorization approval is not a guarantee of payment; claims are evaluated against the member's benefit plan at adjudication.

Documentation Required

Preauthorization and Required Clinical Documentation

Preauthorization must include all required documentation to support medical necessity. Incomplete requests may be delayed or denied. Required documentation generally includes the items below but may vary by plan — always confirm plan-specific requirements.

Comprehensive medical history and physical exam.
Neurology consultation notes detailing MS phenotype, disease course, and current status.
Documentation of prior DMT trials (agents, doses, durations) and why they were inadequate or contraindicated.
Objective evidence of disease activity: recent MRI reports, documented relapses, EDSS or other functional scores.
Organ function testing and pre-transplant evaluation results (cardiac, pulmonary, renal, hepatic labs and imaging).
Formal social work evaluation assessing psychosocial supports, adherence potential, substance/alcohol use, and mental health stability.
Transfusion and donor/source history (including prior transfusions, donor match, cord blood source documentation) because donor/source and transfusion history can impact outcomes and eligibility.
Informed consent discussion documenting risks, potential benefits, and alternative therapies.

Step Therapy

MS Candidate Selection and Step Therapy Considerations

Selection of MS candidates for AHSCT must be clearly documented in the prior authorization submission. Documentation must show the patient meets medical necessity criteria and detail the stepwise care that led to consideration of AHSCT.

Document MS phenotype (RRMS, SPMS with inflammatory activity, etc.) and objective evidence of inflammatory disease activity.
Provide a treatment history showing trials of appropriate DMTs and the rationale for treatment failure, intolerance, or contraindication.
Include objective measures of disability (EDSS or comparable scale) and a narrative explaining anticipated benefit versus risk for AHSCT.
Social work and psychosocial assessment demonstrating support and ability to adhere to follow-up care.

Note

Evaluation Requirements — Operational Notes

Operational notes: one full transplant evaluation per transplant is covered; prior authorization must demonstrate medical necessity and include the complete pre-transplant workup. A documented formal social work evaluation is required to assess support and stability. Prior authorization remains plan-dependent and approval is contingent on member coverage.

One transplant evaluation per transplant is covered.
Formal social work evaluation required.
Prior authorization determinations are plan-dependent and conditional on benefit coverage.

Prior Authorization

Authorization must demonstrate refractory disease and guideline‑aligned patient selection

Prior authorization for aHSCT and related stem cell transplants must show refractory disease despite standard therapies and that patient selection aligns with guideline recommendations (including assessment of patient fitness given peri‑procedural risk).

Demonstrate failure of standard therapies or refractory disease where applicable.
Document guideline‑consistent patient selection and assessment of fitness for transplant.

Prior Authorization

AHSCT (MS) authorizations must document prior DMT failure and candidate thresholds

For AHSCT in multiple sclerosis, prior authorization should include evidence of failure or contraindication to high‑efficacy DMTs or documentation of active inflammatory disease, and relevant candidate data such as age, disease duration, and EDSS/ambulatory status per guideline thresholds.

Provide evidence of clinical relapses or MRI lesion activity despite DMTs (especially high‑efficacy DMTs) or contraindication to DMTs.
Include age, disease duration, and EDSS/ambulatory status to align with guideline‑preferred thresholds.

Billing Rule

Many transplant procedure codes do not require prior authorization for in‑network providers

No prior authorization is required for many listed CPT/HCPCS transplant and related service codes when performed by in‑network providers; some codes are flagged as not payable for Medicaid/Medicare or not covered.

In‑network providers: many transplant procedure codes do not require prior authorization.
Some codes are noted as not payable for Medicaid/Medicare or listed as Not Covered.

Note

Authorization decisions remain subject to member plan terms

Authorization requirements and decisions remain subject to member‑specific plan terms and this policy section does not enumerate every authorization code or step; follow the member's plan provisions.

Authorization is plan‑dependent and subject to the member's benefits and plan documents.
This section provides references but does not replace plan‑specific authorization rules.

Prior Authorization

Second transplant evaluation (second opinion) approved if previously turned down

A second transplant evaluation (second opinion) at a contracted or in‑network transplant facility will be approved if the member has been previously turned down and requests a second evaluation.

Second opinion evaluation approved at contracted/in‑network facility when requested after prior denial.

Note

Follow product‑specific plan documents for authorization and coverage

Follow the member's specific product and plan documents (HMO/EPO, POS, PPO, ASO, Individual, Medicare, Medicaid) for authorization procedures and coverage applicability.

Coverage and authorization processes vary by product; consult the applicable plan document.

Step Therapy

Transplant approval generally after exhaustion of standard‑of‑care therapies

Approval of transplant should generally be considered only after exhaustion of standard‑of‑care medical and surgical therapies (e.g., refractory Crohn's disease) or failure/intolerance to disease‑modifying therapies for conditions like MS, consistent with guideline sequencing.

Document prior standard‑of‑care therapies attempted and failed before transplant consideration.
For MS, document failure/intolerance to DMTs unless aggressive disease justifies earlier AHSCT.

Step Therapy

AHSCT (MS) expected after inadequate response to high‑efficacy DMTs

For multiple sclerosis, step‑therapy expectations require that AHSCT be considered after inadequate response to one or more lines of approved high‑efficacy DMTs, except for selected aggressive presentations where earlier transplant may be appropriate.

Provide documentation of inadequate response to high‑efficacy DMTs when applicable.
Document rationale for earlier transplant in aggressive disease presentations if used.

Documentation Required

Use designated transplant prior authorization form and include evaluation documentation

Providers must submit transplant prior authorization requests using the Bone Marrow/Peripheral Stem Cell or Other Blood Cell transplant form and include the transplant evaluation, social work evaluation, and evidence of organ function and ability to tolerate procedure and immunosuppression.

Use the designated prior authorization transplant form.
Include transplant evaluation, formal social work evaluation, and organ‑function documentation.

Documentation Required

Submit medical‑necessity documentation with prior authorization requests

When prior authorization is required, providers must submit documentation demonstrating the requested transplant is medically necessary as described in the policy and Provider Manual.

Provide evidence that the request meets the policy's medical necessity criteria.

Documentation Required

Document prior therapies and informed consent including trial‑reported serious adverse events

Documentation must include prior therapies attempted and failed for refractory indications and an informed‑consent discussion detailing known serious adverse events reported in trials.

List prior therapies and outcomes (e.g., failed medical/surgical treatments).
Include informed‑consent documentation addressing serious adverse events observed in trials.

Documentation Required

Document MS disease activity, EDSS, age, and prior DMT exposure for AHSCT candidacy

For MS candidates, include documentation of disease phenotype, recent clinical relapses or MRI inflammatory activity despite disease‑modifying therapies, EDSS and ambulatory status, age, and disease duration to support patient selection consistent with guidelines.

Document relapses and/or MRI activity despite DMTs.
Include EDSS, ambulatory status, age, and disease duration.

Billing Rule

Document CPT/HCPCS codes and supporting medical necessity for transplant services

Providers should document CPT/HCPCS procedure codes and supporting medical necessity for transplant‑related services including HLA typing, chimerism analysis, cell harvesting/preparation, and cryopreservation as applicable.

Include procedure codes for HLA typing, chimerism, cell harvest/preparation, cryopreservation, and chemotherapy administration where applicable.
Show clinical rationale linking each code to medical necessity.

Note

Policies are informational; providers remain responsible for supporting documentation

Priority Health medical policies are informational and are not authorization documents; providers remain responsible for documentation supporting claims and authorization per member plan terms.

Policy is informational; verify member eligibility and plan terms for coverage determinations.

Denial Risk

Denial risk: behavioral health and noncompliance exclusions

Priority Health will not cover bone marrow or stem cell transplantation when persistent or active substance or alcohol abuse, psychiatric disease interfering with compliance, or significant history of medical noncompliance is present.

Persistent/active substance or alcohol abuse.
Psychiatric disease that would interfere with pre/post‑transplant compliance.
Significant history of medical noncompliance.

Denial Risk

Denial risk: UCBSCT requires meeting allogeneic SCT selection criteria

Umbilical cord blood stem cell transplant (UCBSCT) will be denied for patients who do not meet the eligibility and patient selection criteria for allogeneic stem cell transplant.

UCBSCT covered only when patient meets all eligibility requirements for allogeneic SCT.
UCBSCT not covered if allogeneic SCT criteria are unmet.

Denial Risk

Denial risk: safety concerns from high rates of serious adverse events

High rates of serious adverse events reported with immune‑ablative HSCT regimens (including treatment‑related deaths, organ failure, thrombotic microangiopathy) may lead to denial for safety concerns when risks outweigh potential benefit.

Serious adverse events in trials include renal failure, thrombotic microangiopathy, respiratory/renal failure, and deaths.
Safety concerns may affect authorization decisions, especially with immune‑ablative regimens.

Denial Risk

Donor/source and transfusion history may affect authorization decisions

Donor/source selection and prior transfusion history impact outcomes; umbilical cord blood transplantation and a history of numerous RBC transfusions are associated with higher non‑relapse mortality and lower overall survival and may influence authorization decisions.

UCB transplantation associated with lower overall survival in analyses.
≥10 prior red blood cell transfusions predicted lower overall survival.

Denial Risk

Denial risk: procedures for not‑covered diagnoses

Claims for indications listed under the NOT COVERED INDICATIONS (document lists multiple ICD‑10 codes) risk denial if submitted for stem cell or bone marrow transplantation services.

Numerous diagnoses are listed as Not Covered; verify indication against the Not Covered list before submission.
Claims for listed indications are at risk of denial.

Note

Coverage conditional on member’s plan terms and eligibility

Receipt of benefits is conditional on satisfaction of all terms and conditions of the member's plan in effect on the date of service; eligibility and benefit coverage are determined per the member's plan.

Verify member eligibility and applicable plan terms prior to authorizing or billing for services.

For non‑contracted facilities beyond one year, only physician services are covered; testing, labs, and imaging are covered in‑network only.

One evaluation per transplantPre‑transplant evaluation: one transplant evaluation per transplant is covered (see Provider Manual for details).

General post-transplant services

Benefit subject to plan termsCoverage and follow‑up are subject to member‑specific benefits and the applicable plan documents; group‑specific policy may supersede.

Product applicabilityPolicy applies variably to HMO/EPO, POS, PPO, ASO, Individual, Medicare, and Medicaid products; consult plan documents for conflicts.

Preauthorization dependencyPrior authorization requirements and documentation may vary by product and plan; follow the Priority Health Provider Manual.

Inpatient and outpatient post-transplant care

Monitoring and complication managementPost‑transplant monitoring and management of complications (including inpatient and outpatient care) is critical given the high incidence of serious adverse events reported with HSCT.

Intensity of follow‑upCoverage should accommodate intensive follow‑up and management of organ‑specific complications and late effects related to conditioning and immunosuppression.

Center expertiseManagement is best delivered at experienced, accredited transplant centers able to address treatment‑related mortality and late effects.

Surveillance for relapse/progression, complications, and functional outcome assessments

Surveillance prioritiesSurveillance should include monitoring for relapse/progression, infections, graft‑versus‑host disease, and functional outcome assessments.

Follow‑up duration reportedReported study and registry follow‑up ranges from months to years; specific surveillance schedules vary by indication and center.

Importance of outcome measuresFunctional outcomes (eg, wound healing in EB, visual function in RP, EDSS in MS) and survival/complication tracking are emphasized in evidence summaries.

Post-transplant aftercare and status coding

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

Transplant status codesZ94.81 — Bone marrow transplant status; Z94.89 — Stem cells transplant status.

Use caseThese diagnosis codes support post‑transplant encounters and documentation for aftercare and transplant status in medical records and claims.

Autologous — Autologous hematopoietic stem cell transplantation definition

DefinitionAutologous hematopoietic stem cell transplantation (aHSCT): the patient's own hematopoietic stem cells are collected, the patient undergoes conditioning to ablate or suppress the immune system, and the collected cells are reinfused to reconstitute hematopoiesis and immunity.

Typical usesaHSCT is commonly used for certain autoimmune diseases (eg, MS) and hematologic malignancies where reinfusion of the patient's cells is appropriate.

Risk profileaHSCT avoids donor‑related risks (eg, GVHD) but still carries significant short‑ and long‑term toxicity related to conditioning regimens.

Tandem transplantation — Definition

DefinitionTandem transplantation: two or more planned courses of high‑dose chemotherapy with stem cell support, typically administered at intervals of two to six months contingent on recovery from prior toxicity.

DistinctionTandem transplants differ from multiple cycles with longer recovery intervals; timing is planned to achieve sequential high‑dose therapy.

Coverage noteTandem transplants may be covered or excluded depending on the specific condition and policy section.

Partial remission — Definition

Partial remissionDefined as at least a 50% reduction in tumor burden.

ContextUsed to classify treatment response for transplant eligibility and coverage decisions.

Relation to responsiveness'Responsive' tumors include those in complete or partial remission per definitions in the policy.

Sources of stem cells

Sources listedSources of stem cells include autologous (patient), syngeneic (identical twin), allogeneic (donor), and umbilical cord blood (neonatal source).

Collection methodsAutologous and allogeneic stem cells can be harvested from bone marrow or peripheral blood (pheresis); cord blood is collected at delivery.

Immunologic implicationsDifferent sources have differing immunologic properties and risks (eg, cord blood is antigenically naive with lower GVHD rates).

Autologous hematopoietic stem cell transplantation (aHSCT)

aHSCT descriptionAutologous HSCT involves collection of a patient's own hematopoietic stem cells, conditioning to ablate the immune system, and reinfusion to reconstitute immunity; commonly used in severe autoimmune diseases and certain malignancies.

Procedure elementsIncludes mobilization/harvest (often with cyclophosphamide or growth factors), conditioning regimen, reinfusion, and post‑transplant care including immunosuppression when indicated.

Candidate considerationsPatient selection favors younger, ambulatory individuals with inflammatory disease activity for autoimmune indications like MS.

Disease activity (MS) — Definition

Disease activity (MS)Defined as clinical relapses or MRI lesion activity indicating inflammatory activity in multiple sclerosis.

Role in eligibilityEvidence of disease activity despite DMTs is a key criterion for considering AHSCT in MS patients.

Assessment methodsDocumented clinical relapses and MRI with gadolinium‑enhancing lesions are used to demonstrate activity per policy criteria.

AHSCT — Abbreviation

AbbreviationAHSCT — Autologous hematopoietic stem cell transplantation.

UsageUsed throughout the policy in indications such as multiple sclerosis and certain autoimmune diseases.

ImplicationImplies immune ablation followed by reconstitution with autologous stem cells.

BM-MSC — Bone marrow–derived mesenchymal stem cells

BM‑MSC definitionBM‑MSC — Bone marrow–derived mesenchymal stem cells used as cell‑based therapy in various conditions; evidence in ALS and other indications is low‑certainty.

Evidence noteBM‑MSC trials in ALS report small RCTs with limited follow‑up and uncertain effects on survival or muscle strength.

Clinical contextBM‑MSC therapies have been explored in RDEB and RP with varying results; delivery method and source influence outcomes.

Thrombotic thrombocytopenic purpura (TTP) — Definition

TTP definitionThrombotic thrombocytopenic purpura (TTP): a rare, life‑threatening thrombotic microangiopathy caused by severe ADAMTS13 deficiency leading to microvascular thrombosis.

Clinical urgencyAcute TTP is a medical emergency with high untreated mortality; standard care includes plasma infusion/exchange and immunosuppression.

Stem cell roleStem cell therapy has been proposed but lacks sufficient recent evidence due to the rarity of the condition.

Retinitis pigmentosa (RP) — Definition

RP definitionRetinitis pigmentosa (RP): a group of hereditary retinal dystrophies with progressive photoreceptor degeneration leading to night blindness, constricted visual fields, and progressive visual acuity loss.

Prognostic variabilityPrognosis varies by genetic subtype, age of onset, and progression rate.

Therapeutic contextMSC therapies have shown short‑term improvements in visual function in some studies but long‑term efficacy remains uncertain.

EBMT / JACIE — Society and accreditation definitions

EBMT / JACIEEBMT: European Society for Blood and Marrow Transplantation; JACIE: Joint Accreditation Committee of ISCT and EBMT — organizations cited for guideline and accreditation recommendations for transplant centers.

RoleRecommendations from EBMT and other societies inform candidate selection and center accreditation expectations for AHSCT and allogeneic transplants.

Guideline linkagePolicy references EBMT/NMSS/ASTCT guidance for MS and other indications when defining candidate and center criteria.