ModifiedUnitedHealthcarePolicy CS127PA.O

Umbilical Cord Blood Harvesting And Storage Future Use Pa Cs

Pennsylvania-only UnitedHealthcare medical policy governing coverage determination for prophylactic collection and storage (private banking) of umbilical cord and placental blood for potential future autologous or allogeneic use; references related guidance and codes.

Policy Summary

PayerUnitedHealthcare

PolicyUmbilical Cord Blood Harvesting And Storage Future Use Pa Cs

Policy CodePolicy CS127PA.O

Change TypeCoverage Rationale revised; supporting sections updated

Effective DateOct 1, 2025

Next Review Date

Key ActionProphylactic/private cord blood collection and storage for future unspecified use is not medically necessary and will not be covered; providers should obtain benefit confirmation and follow state/contractual requirements when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale language was revised to specify 'prophylactic collection and storage of umbilical cord blood is unproven and not medically necessary for an individual who is currently healthy but desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation due to insufficient evidence of efficacy.'

Updated Clinical Evidence and References sections to reflect most current information.

1States applicable

0Covered indications for prophylactic private banking

4Referenced CPT codes

Coverage Summary

This Pennsylvania-only UnitedHealthcare medical policy addresses coverage determinations for the prophylactic collection and private banking (storage) of umbilical cord and placental blood for potential future autologous or allogeneic use.

Policy Snapshot

Effective DateOctober 1, 2025

Policy NumberCS127PA.O

Policy StatusMODIFIED

States applicable1

Covered indications for prophylactic private banking0

Referenced CPT codes4

Medical‑Necessity Criteria

Not Medically Necessary (Prophylactic Collection and Storage)

Covered when ALL of the following are met:

ALL of the following

Prophylactic collection and storage of umbilical cord blood is performed for an individual who is currently healthy and desiring to provide the opportunity for a future unspecified autologous or allogeneic stem cell transplantation
There is insufficient evidence of efficacy to support prophylactic collection and storage for future unspecified use

Exceptions / Directed Banking Consideration (Guideline-based, not coverage criteria)

Professional society recommendations referenced (informational):

ANY of the following

Not Medically Necessary / Not Covered

Prophylactic/private collection and storage of umbilical cord blood for an individual who is currently healthy and seeking to preserve the option of a future unspecified autologous or allogeneic transplant is considered not medically necessary and will not be covered. The Coverage Rationale language was revised to clarify this policy position.

Coding

Referenced Procedure CodesCPT

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.
88240	Cryopreservation, freezing and storage of cells, each cell line

Provider Actions

Prior Authorization

Coverage determination required for cord blood banking

Prophylactic/private cord blood collection and storage for future unspecified use is considered not medically necessary and therefore will not be covered; providers should obtain benefit confirmation and follow state/contractual requirements when requesting coverage.

Documentation Required

Apply Pennsylvania-specific policy and exceptions

This policy applies only to Pennsylvania; requests not meeting criteria in the PARP will be evaluated case-by-case and reference Pennsylvania Code, Title 55, Chapter 1101.

Background

Umbilical cord and placental blood are sources of hematopoietic stem cells that can be cryogenically banked. Cord blood may be stored privately for potential autologous or family use or donated to public banks for broader access. Professional societies generally encourage public banking and do not support routine prophylactic private banking for healthy, low-risk families; directed banking is recommended when there is a known at-risk family member (for example, a full sibling) who may benefit from cord blood transplantation.

Definitions

Prophylactic collection and storageCollection and banking of cord blood from a healthy newborn for potential unspecified future use by the donor or family member.

Clinical Evidence

Clinical evidence search

No high-quality studies were identified that evaluate the storage of umbilical cord blood for hypothetical or unspecified future use.

Revision History

10/01/2025revisedLatest

10/01/2025clarified

Archived previous policy version CS127PA.N. Updated Clinical Evidence and References sections to reflect most current information.