Hematopoietic Cell Transplantation: Experimental/Investigational Services

Policy ID: S-271-003

Section: Surgery

Effective Date: May 02, 2022

Revised Date: May 13, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

This policy addresses hematopoietic cell transplantation (HCT) services considered to be experimental/investigational for the listed disease states (not an all-inclusive list).

Hematopoietic cell transplantation (HCT) involves the intravenous (IV) infusion of allogeneic (donor) or autologous stem cells to reestablish hematopoietic function in individuals whose bone marrow or immune system is damaged or defective. They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Allogeneic or autologous HCT services to treat the following diseases or malignancies are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of the services cannot be established by the available published peer-reviewed literature:

Cancer(s), Adult, including but not limited to:
- Breast; or
- Bile duct; or
- Fallopian tubes; or
- Cervical; or
- Colon; or
- Esophageal cancer; or
- Gall bladder cancer; or
- Lung, any histology; or
- Ovarian cancer, epithelial, advanced stage; or
- Melanoma, malignant; or
- Nasopharyngeal; or
- Pancreatic; or
- Paranasal sinus; or
- Prostate; or
- Rectal; or
- Renal cell; or
- Stomach; or
- Uterine; or
Gliomas, malignant, including but not limited to:
- Astrocytoma, malignant; or
- Glioblastoma multiforme; or
- Oligodendroglioma; or
Tumors, adult, including but not limited to:
- Neuroendocrine; or
- Origin, primary, unknown; or
- Thyroid; or
- Thymus.

Procedure Codes

38205

38206

38240

38241

S2140

S2142

S2150

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) - 2022

NCCN guidelines do not address HCT to treat any of the above-mentioned diseases or carcinomas.

ND Committee Review

Internal Medical Policy Committee 3-23-2022 New policy for ND

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 5-13-2025 Revision- Effective July 07, 2025

Removed bullet (sarcoma, soft tissue)

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-271-002

Section: Surgery

Effective Date: May 02, 2022

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Applies To: Commercial and Medicaid Expansion

Description

This policy addresses hematopoietic cell transplantation (HCT) services considered to be experimental/investigational for the listed disease states (not an all-inclusive list).

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Cancer(s), Adult, including but not limited to:
- Breast; or
- Bile duct; or
- Fallopian tubes; or
- Cervical; or
- Colon; or
- Esophageal cancer; or
- Gall bladder cancer; or
- Lung, any histology; or
- Ovarian cancer, epithelial, advanced stage; or
- Melanoma, malignant; or
- Nasopharyngeal; or
- Pancreatic; or
- Paranasal sinus; or
- Prostate; or
- Rectal; or
- Renal cell; or
- Sarcoma, soft tissue; or
- Stomach; or
- Uterine; or
Gliomas, malignant, including but not limited to:
- Astrocytoma, malignant; or
- Glioblastoma multiforme; or
- Oligodendroglioma; or
Tumors, adult, including but not limited to:
- Neuroendocrine; or
- Origin, primary, unknown; or
- Thyroid; or
- Thymus.

Procedure Codes

38205

38206

38240

38241

S2140

S2142

S2150

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) - 2022

NCCN guidelines do not address HCT to treat any of the above-mentioned diseases or carcinomas.

ND Committee Review

Internal Medical Policy Committee 3-23-2022 New policy for ND

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Hematopoietic Cell Transplantation: Experimental/Investigational Services

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) - 2022

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer