Does Ambetter require prior authorization for 86817?

Ambetter lists 86817 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for 86817?

Anthem BCBS lists 86817 on Virginia Local Precertification/Prior Authorization List (HMO & EPO) for commercial plans, with conditions (list dated September 1, 2026). Verify with the payer before scheduling.

Does Blue Shield of California require prior authorization for 86817?

Blue Shield of California lists 86817 on Prior Authorization List for Blue Shield of California for commercial plans (list dated October 1, 2026). Verify with the payer before scheduling.

Does Coordinated Care require prior authorization for 86817?

Coordinated Care lists 86817 on Coordinated Care CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 86817?

There are 38 tracked policy changes affecting CPT 86817, including updates from Ambetter, Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 86817?

Payers that have issued tracked updates for CPT 86817 include: Ambetter, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when CPT 86817 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 86817. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 86817?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

PAYER POLICY CHANGES

86817 Insurance Policy Changes

CPT 86817 is referenced in 38 tracked payer policy changes from Ambetter, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 86817 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Ambetter · Effective Jan 1, 2027High impact
August Provider Newsletter
Ambetter of North Carolina will stop covering a list of HCPCS H codes starting January 1, 2027, and will cover H0006 from that date. Earlier changes are already effective: CPT 80320-80377 drug testing codes were no longer reimbursable from October 1, 2026, and the prior authorization changes effective October 1, 2026 took effect. The newsletter also covers surrogacy diagnosis codes Z33.3 and Z31.7, behavioral health type of bill guidance, and clinical policy updates effective 11/1/2026.
Ambetter · Effective Oct 1, 2026High impact
Ambetter of Tennessee Q3 2026 Newsletter
Already effective October 1, 2026, prior authorization is removed for genetic testing codes 86812, 86813, and 86817, home visit codes S9211, S9213, and S9214, and medical transportation mileage code 38208, while sinus surgery code 31297 now requires prior authorization. CPT codes 80320 through 80377 for definitive drug testing are no longer reimbursable as of October 1, 2026. Effective December 5, 2026, Evolent will guide ordering providers to select a preferred site of care for shoulder, hip, knee, and spine surgeries, and effective January 1, 2027, Evolent will require prior authorization for listed cardiology and vascular procedure codes.
Ambetter · Effective Oct 1, 2026High impact
Effective 10/1/26: Removal of Prior Authorization Requirement for Certain Procedures
Effective October 1, 2026, Superior HealthPlan will remove prior authorization requirements for 13 specific procedure codes across Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter Health plans. Billing teams must update their prior authorization workflows to stop requiring PA for these codes to avoid unnecessary delays and claim processing issues.
Ambetter · Effective Oct 1, 2026High impact
Q3 2026 Provider Newsletter
Ambetter of Alabama updated its prior authorization requirements effective Oct. 1, 2026. The updated table lists genetic testing codes 81378, 81379, 81380, 81381, 81382, 81383, 86812, 86813 and 86817 as No PA Required, sinus procedure codes 31296 and 31297 as PA Required, and transplant code 38208 as No PA Required. Starting Dec. 5, 2026, Evolent will guide ordering providers to select a preferred site of care when they submit authorization requests for shoulder, hip, knee and spine surgeries.
Ambetter · Effective Oct 1, 2026High impact
Effective October 1, 2026: Removal of Prior Authorization Requirement for Certain Procedures
Effective October 1, 2026, Superior HealthPlan (Ambetter Health, Medicaid, CHIP) is removing prior authorization requirements for specific procedures across multiple service categories including genetic analysis, home services, transplant services, behavioral health, sleep medicine, durable medical equipment, and hearing services. Billing teams must update systems to stop requesting prior authorization for the listed procedure codes to avoid unnecessary delays and claim processing issues.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Meridian is removing prior authorization requirements for genetic testing, home visit services, and transplant services, while adding prior authorization requirements for specific sinus surgery procedures (31296, 31297, 31298), effective October 1, 2026. These changes apply across Ambetter's markets and lines of business to simplify the prior authorization process.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates
Ambetter from Magnolia Health is updating prior authorization requirements effective October 1, 2026. Genetic testing (CPT 81378-81383, 86812-86813, 86817), home services (S9211, S9213, S9214), and transplant services (CPT 38208) no longer require prior authorization, while sinus surgery (CPT 31297) now requires prior authorization. These changes standardize PA requirements across markets and lines of business.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Buckeye Health Plan is removing prior authorization requirements for genetic testing, obstetrical home services, and transplant services for participating providers effective October 1, 2026. Simultaneously, prior authorization is now required for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter of Alabama is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing (CPT 86812, 86813, 86817) and transplant services (CPT 38208), while adding PA requirements for sinus surgery procedures (CPT 31296, 31297). These changes aim to reduce administrative burden and standardize PA processes across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter Health is updating prior authorization requirements effective October 1, 2026. The changes remove PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while adding PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter Health of Delaware is updating prior authorization (PA) requirements effective October 1, 2026. Genetic testing (CPT 86812, 86813, 86817) and home visit services (HCPCS S9211, S9213, S9214) are moving to NO PA REQUIRED, while sinus surgery procedures (CPT 31276, 31296, 31297, 31298) now require PA. Changes aim to reduce administrative burden and create uniform PA requirements across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Absolute Total Care is removing prior authorization requirements for genetic testing, home services, and transplant services effective October 1, 2026, while adding prior authorization requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and streamline the PA process across markets and lines of business.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Arizona Complete Health is removing prior authorization requirements for genetic testing (CPT 86812, 86813, 86817), home services (HCPCS S9211, S9213, S9214), and transplant services (CPT 38208), while adding prior authorization requirements for sinus surgery procedures (CPT 31276, 31296, 31297, 31298). These changes take effect October 1, 2026, and aim to reduce administrative burden and simplify the PA process across markets and lines of business.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates (Effective October 1, 2026)
Ambetter Health is simplifying prior authorization requirements effective October 1, 2026, by removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures (31296, 31297). This change aims to reduce administrative burden and create uniform PA requirements across all markets and lines of business.
Aetna · Identified Oct 4, 2026Medium impact
Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia (CPB 0626, reviewed 2026-09-18)
Aetna's Clinical Policy Bulletin 0626 considers allogeneic hematopoietic cell transplantation medically necessary for thalassemia major and sickle cell anemia in children or young adults when the member meets the transplanting institution's written eligibility criteria. Where no such criteria exist, Aetna considers it medically necessary for thalassemia major in children or young adults with a haploidentical or HLA-matched donor, and for sickle cell anemia when the member has a haploidentical or HLA-matched donor and either a history of stroke or an increased risk of stroke or end-organ damage. Autologous transplant for thalassemia major or sickle cell anemia in children or young adults, treosulfan-based T-cell depleted haploidentical transplant for sickle cell disease or transfusion-dependent thalassemia, and use of T-lymphocyte subsets at engraftment to predict acute graft-versus-host disease risk are considered experimental, investigational or unproven.
Aetna · Identified Oct 4, 2026Medium impact
Hematopoietic Cell Transplantation for Selected Leukemias (CPB 0640, reviewed 2026-09-11)
Aetna's clinical policy bulletin CPB 0640 (reviewed 2026-09-11, first detected here 2026-10-04, so this is historical material) sets when stem cell transplant is covered for acute lymphocytic, myeloid and other leukemias. It covers allogeneic transplants for most of these leukemias when the transplant center's criteria are met, but it lists autologous transplant for ALL, CMML and JMML, tandem transplants for ALL, repeat transplants for AML that has not gone into remission, hepcidin testing and micro-transplantation as experimental. The notice gives no new effective date and does not say what changed in this review, so confirm the current bulletin with Aetna before acting on it.
Aetna · Identified Oct 4, 2026Medium impact
Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes (CPB 0627, reviewed 2026-09-23)
Aetna's Clinical Policy Bulletin 0627 covers allogeneic hematopoietic cell transplantation for severe aplastic anemia, Diamond-Blackfan anemia, Fanconi's anemia, paroxysmal nocturnal hemoglobinuria, and pure red cell aplasia when the transplanting institution's selection criteria are met. Where institution criteria are not available, Aetna considers allogeneic transplant medically necessary for severe aplastic anemia with marrow cellularity less than 25% (or 25% to 50% with less than 30% hematopoietic cells) and at least 2 of 3 peripheral blood cytopenias, and for repeat allogeneic transplant after primary graft failure, failure to engraft or rejection. Autologous hematopoietic cell transplantation for these conditions is considered experimental, investigational or unproven.
Aetna · Identified Oct 4, 2026Medium impact
Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2026-09-18)
Aetna considers autologous hematopoietic cell transplantation medically necessary for adults 18 to 69 years old with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure. This applies when active interstitial lung disease is present with a forced vital capacity or diffusing capacity of the lung for carbon monoxide below 70% of predicted, or when previous scleroderma-related renal disease is present, and the member meets the transplanting institution's selection criteria or, if there are none, has none of the listed exclusion criteria. Aetna considers autologous or allogeneic hematopoietic cell transplantation experimental, investigational, or unproven for conditions including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, ulcerative colitis, myasthenia gravis, type I diabetes mellitus, age-related macular degeneration, amyotrophic lateral sclerosis, polycythemia vera, and thrombotic thrombocytopenic purpura.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)
Aetna's Clinical Policy Bulletin 0811 considers autologous or allogeneic hematopoietic stem cell transplant, both ablative and non-myeloablative, experimental, investigational, or unproven for the following adult solid tumors: bile duct (cholangiocarcinoma), breast, central nervous system tumors, cervix, colon, esophagus, fallopian tube, gallbladder, kidney, liver, lung, melanoma, nasopharynx, neuroendocrine tumors, pancreas, paranasal sinus, prostate, rectum, soft tissue sarcomas, stomach, thymus, thyroid, tumors of unknown primary origin, and uterus. Aetna considers autologous hematopoietic stem cell transplant medically necessary in young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family of tumors when criteria are met in CPB 0496.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)
Aetna considers autologous hematopoietic cell transplantation medically necessary as consolidation therapy for high-risk neuroblastoma when the member meets the transplanting institution's protocol selection criteria. Without a protocol, it is considered medically necessary when the stated criteria are met, including tandem autologous transplants for the common high-risk group and a single autologous transplant for the special high-risk groups. Autologous transplant is not medically necessary for members with progressive disease during or at the end of induction therapy. Autologous transplant is also addressed for chemosensitive relapsed or refractory neuroblastoma, relapsed or progressive chemosensitive Ewing's sarcoma family of tumors that is not widely metastatic, primitive neuroectodermal tumors including medulloblastoma and pineoblastoma, ependymoma in members ineligible for radiotherapy, extraocular retinoblastoma, and progressive or relapsed chemosensitive Wilms' tumor. Allogeneic hematopoietic cell transplantation for ependymoma, Ewing's sarcoma family of tumors, neuroblastoma, primitive neuroectodermal tumors, retinoblastoma and Wilms' tumor, adoptive cellular immunotherapy following transplantation for childhood solid tumors, and autologous transplantation for soft tissue sarcomas are considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma (CPB 0494, reviewed 2026-08-03)
Aetna Clinical Policy Bulletin 0494 covers hematopoietic cell transplantation for non-Hodgkin's lymphoma (NHL). Aetna considers autologous transplant medically necessary for relapsed or primary refractory NHL when the transplanting institution's protocol criteria are met, or, without a protocol, when the person has relapsed or refractory NHL with evidence of chemotherapy-responsive disease. Aetna considers allogeneic transplant medically necessary for relapsed NHL (including relapse after autologous transplant) or primary refractory NHL when a suitable HLA-matched or haploidentical donor or matched cord blood is available and there is no serious organ dysfunction, and considers tandem autologous and autologous-allogeneic transplants experimental, investigational, or unproven for NHL.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Myelodysplastic Syndrome (CPB 0836, reviewed 2025-12-09)
Aetna Clinical Policy Bulletin 0836 covers hematopoietic cell transplantation (HCT) for myelodysplastic syndrome (MDS). Aetna considers allogeneic HCT (ablative or non-myeloablative) medically necessary for individuals with intermediate-risk or high-risk MDS who have not responded to prior therapy and have an available HLA-compatible donor. Aetna considers a repeat allogeneic HCT medically necessary for intermediate-risk or high-risk MDS due to primary graft failure, failure to engraft, or late relapse (greater than 18 months after HCT), and considers a repeat allogeneic HCT for early relapse, and autologous HCT for MDS, experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Multiple Myeloma (CPB 0497, reviewed 2026-08-05)
Aetna considers autologous hematopoietic cell transplantation medically necessary for multiple myeloma or POEMS syndrome when the transplanting institution's written eligibility criteria are met. Without such criteria, it is considered medically necessary when the member has no significant co-morbid medical conditions and adequate major organ function based on the transplant institution's evaluation, and indolent myeloma, smoldering myeloma and MGUS are excluded. Allogeneic transplant is considered medically necessary for multiple myeloma or POEMS syndrome when the member meets the transplanting institution's protocol criteria, or without a protocol when the member has adequate major organ function and early relapse (less than 24 months) after primary therapy that included an autologous transplant (multiple myeloma only). Tandem transplants require protocol criteria or, without a protocol, active myeloma with the first and second transplants planned within a 6-month period, and exclusions include inadequate cardiac, pulmonary or hepatic function, another life-limiting cancer, and psychiatric disease that would interfere with the regimen. The use of natural killer cells in autologous stem cell transplantation for multiple myeloma is considered experimental, investigational or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Hodgkin's Disease (CPB 0495, reviewed 2026-07-02)
Aetna considers autologous hematopoietic cell transplantation medically necessary for Hodgkin's disease when the member meets the transplanting institution's selection criteria, or, in the absence of such criteria, when the member is in primary induction failure or beyond first remission and is without serious organ dysfunction based on the transplanting institution's evaluation. Allogeneic transplantation is medically necessary under the same conditions for relapsed or primary refractory Hodgkin's disease, including disease that relapsed or persisted after an autologous transplant, and non-myeloablative allogeneic transplantation is medically necessary for these members when they are eligible for conventional allografting. Tandem (sequential) transplants are considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2025-09-10)
Aetna's Clinical Policy Bulletin 0606 covers hematopoietic cell transplantation for autoimmune diseases and other listed conditions. Aetna considers autologous transplant medically necessary for adults aged 18 to 69 with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure when either active interstitial lung disease with an FVC or DLCO below 70% of predicted is present, or previous scleroderma-related renal disease is present, and the member meets the transplanting institution's selection criteria or, where none exist, has none of the listed exclusion criteria. Aetna considers autologous or allogeneic transplant experimental, investigational or unproven for many autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, ulcerative colitis, type 1 diabetes and myasthenia gravis, and for miscellaneous conditions such as age-related macular degeneration, amyotrophic lateral sclerosis, polycythemia vera and thrombotic thrombocytopenic purpura.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes (CPB 0627, reviewed 2025-12-11)
Aetna considers allogeneic hematopoietic cell transplantation medically necessary for severe aplastic anemia, Diamond-Blackfan anemia, Fanconi's anemia, paroxysmal nocturnal hemoglobinuria and pure red cell aplasia when members meet the transplanting institution's selection criteria, and sets specific disease criteria when the institution has none. Aetna considers repeat allogeneic stem cell transplantation medically necessary for primary graft failure, failure to engraft or rejection in these conditions. Autologous hematopoietic cell transplantation is considered experimental, investigational or unproven for these indications.
Aetna · Identified Aug 17, 2026Medium impact
Stem Cells for Hematopoietic Cell Transplant (CPB 0190, reviewed 2026-03-27)
Aetna considers compatibility testing and short-term harvesting and storage of stem cells from close family donors medically necessary when an allogeneic bone marrow or peripheral stem cell transplant is authorized by Aetna, and considers umbilical cord blood an acceptable alternative to conventional bone marrow or peripheral stem cells for allogeneic transplant. Short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment is covered when there is a match, and stem cell boosting for graft failure after an approved allogeneic transplant is covered when criteria are met. Co-transplantation of mesenchymal stromal cells, the Portomar bone marrow access device, the ELISPOT assay for predicting CMV infection risk, mesenchymal stromal cell-derived extracellular vesicles for GVHD, and umbilical cord blood transplantation using ex-vivo expansion are considered experimental, investigational or unproven.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem-Cells for Treatment of Malignancy
Nonmyeloablative allogeneic stem cell transplantation may be considered medically necessary in patients who would otherwise meet the patient selection criteria for high-dose chemotherapy and allogeneic stem cell transplantation, as set out in the related policies for non-Hodgkin lymphomas, myelodysplastic syndromes and myeloproliferative neoplasms, acute myeloid leukemia, Hodgkin lymphoma, chronic myeloid leukemia and acute lymphoblastic leukemia. Other applications are considered investigational, including use in patients who do not meet those criteria due to age or comorbidities, and treatment of multiple myeloma, renal cell carcinoma, other solid tumors or autoimmune disease. No benefits are provided for a covered transplant procedure or transplant evaluation unless the member receives prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant
Donor lymphocyte infusion may be considered medically necessary after an allogeneic hematopoietic stem cell transplant that was originally medically necessary for a hematologic malignancy that has relapsed or is refractory, to prevent relapse when the risk of relapse is high, or to convert a patient from mixed to full donor chimerism. It is considered investigational after an allogeneic transplant that was originally investigational for a hematologic malignancy, as a treatment of nonhematologic malignancies following a prior allogeneic transplant, and when donor leukocytes have been genetically or otherwise modified. The policy exceptions were updated on 04/29/2024 for Federal Employee Program and State and School Employee subscribers.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
8.01.20 on hematopoietic cell transplantation for non-Hodgkin lymphomas. Allogeneic transplant with a myeloablative conditioning regimen or autologous transplant may be considered medically necessary for aggressive B-cell subtypes (except mantle cell lymphoma) as salvage therapy, to achieve or consolidate complete remission in a chemosensitive relapse, or to consolidate a first complete remission in diffuse large B-cell lymphoma with a high or high-intermediate risk International Prognostic Index score. Tandem transplants and autologous or allogeneic transplants as initial therapy are considered investigational. A 07/16/2026 policy history entry changed 'patients' to 'individuals' in the description, policy statement and guidelines and removed ICD-9 codes from the code reference.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
8.01.21 on allogeneic hematopoietic cell transplantation for myelodysplastic syndromes and myeloproliferative neoplasms. Myeloablative allogeneic transplant may be considered medically necessary as a treatment for these disorders, and reduced-intensity conditioning allogeneic transplant may be considered medically necessary as a risk-adapted treatment for individuals at high risk of intolerance of a myeloablative regimen. Myeloablative or reduced-intensity allogeneic transplant for cases that do not meet the policy guidelines criteria is investigational. A 07/23/2026 policy review updated the description with minor changes, left the policy statements unchanged and removed ICD-9 procedure and diagnosis codes from the code reference.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
8.01.24 on hematopoietic cell transplantation for miscellaneous solid tumors in adults. Autologous or allogeneic hematopoietic cell transplantation is considered investigational for the following adult malignancies, including lung cancer of any histology, colon, rectal, pancreatic, stomach, esophageal, renal cell, prostate and uterine cancers, soft tissue sarcomas, neuroendocrine tumors, thyroid tumors and malignant melanoma. A 07/23/2026 policy review left the policy statement unchanged and removed ICD-9 procedure codes from the code reference.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
Single autologous hematopoietic cell transplantation may be considered medically necessary as salvage therapy for germ cell tumors in individuals with favorable prognostic factors who have failed a previous course of conventional-dose salvage chemotherapy, and in individuals with unfavorable prognostic factors as initial treatment of first relapse or with platinum-refractory disease. Tandem autologous transplant or transplant with sequential high-dose chemotherapy may be considered medically necessary for testicular tumors as salvage therapy or with platinum-refractory disease, while autologous transplant as a component of first-line treatment and allogeneic transplant to treat germ cell tumors are considered investigational. The policy history records a review on 07/27/2026 with policy statements unchanged and ICD-9 procedure and diagnosis codes removed from the Code Reference section.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Cell Transplantation for Solid Tumors of Childhood
Autologous hematopoietic cell transplantation may be considered medically necessary at initial treatment of high-risk neuroblastoma and high-risk Ewing sarcoma, for recurrent or refractory neuroblastoma and Ewing sarcoma, and for metastatic retinoblastoma. Tandem autologous transplant may be considered medically necessary for high-risk neuroblastoma. Autologous transplant is considered investigational as initial treatment of low- or intermediate-risk neuroblastoma and Ewing sarcoma and for rhabdomyosarcoma, Wilms tumor, osteosarcoma and retinoblastoma without metastasis, and allogeneic transplant for pediatric solid tumors and salvage allogeneic transplant after relapse or failure of response to autologous transplant are considered investigational.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Cell Transplantation for Primary Amyloidosis or Waldenstrom's Macroglobulinemia
Autologous hematopoietic cell transplantation may be considered medically necessary to treat primary systemic amyloidosis and as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic cell transplantation is considered investigational to treat both primary systemic amyloidosis and Waldenstrom macroglobulinemia. The policy history records a review on 07/27/2026 with policy statements unchanged and ICD-9 procedure and diagnosis codes removed from the Code Reference section.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Stem-Cell Transplantation for Breast Cancer
Single or tandem autologous hematopoietic stem-cell transplantation is considered not medically necessary to treat any stage of breast cancer. Allogeneic hematopoietic stem-cell transplantation is investigational to treat any stage of breast cancer. No benefits will be provided for a covered transplant procedure unless the member receives prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Placental and Umbilical Cord Blood as a Source of Stem Cells
Transplantation of cord blood stem cells from related or unrelated donors may be considered medically necessary for patients with an appropriate indication for allogeneic stem cell transplant, and it is investigational in all other situations. Collection and storage of a neonate's cord blood may be considered medically necessary when an allogeneic transplant is imminent in an identified recipient with a consistent diagnosis, while prophylactic collection and storage for unspecified future autologous or allogeneic use is considered not medically necessary. No benefits are provided for a covered transplant procedure or transplant evaluation unless the member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
Aetna · Identified Nov 5, 2026Low impact
Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2026-10-29)
Aetna's Clinical Policy Bulletin 0811 (last reviewed 2026-10-29) confirms that autologous and allogeneic hematopoietic cell transplantation for most adult solid tumors is considered experimental, investigational, or unproven and not covered, with listed CPT, HCPCS, and ICD-10 codes marked as not covered for those indications. The only exceptions are young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family tumors, which fall under CPB 0496 criteria. The source states no specific effective date for a change; the listed effective date (02/04/2011) is the original policy date and the next review is 09/09/2027.

Watch 86817

Get one email when a payer policy names 86817, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

See every payer rule for 86817

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 86817 in one place.

See every payer rule

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

August Provider Newsletter

Ambetter of Tennessee Q3 2026 Newsletter

Effective 10/1/26: Removal of Prior Authorization Requirement for Certain Procedures

Q3 2026 Provider Newsletter

Effective October 1, 2026: Removal of Prior Authorization Requirement for Certain Procedures

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates (Effective October 1, 2026)

Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia (CPB 0626, reviewed 2026-09-18)

Hematopoietic Cell Transplantation for Selected Leukemias (CPB 0640, reviewed 2026-09-11)

Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes (CPB 0627, reviewed 2026-09-23)

Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2026-09-18)

Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)

Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)

Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma (CPB 0494, reviewed 2026-08-03)

Hematopoietic Cell Transplantation for Myelodysplastic Syndrome (CPB 0836, reviewed 2025-12-09)

Hematopoietic Cell Transplantation for Multiple Myeloma (CPB 0497, reviewed 2026-08-05)

Hematopoietic Cell Transplantation for Hodgkin's Disease (CPB 0495, reviewed 2026-07-02)

Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2025-09-10)

Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes (CPB 0627, reviewed 2025-12-11)

Stem Cells for Hematopoietic Cell Transplant (CPB 0190, reviewed 2026-03-27)

Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem-Cells for Treatment of Malignancy

Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant

Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

Hematopoietic Cell Transplantation for Solid Tumors of Childhood

Hematopoietic Cell Transplantation for Primary Amyloidosis or Waldenstrom's Macroglobulinemia

Hematopoietic Stem-Cell Transplantation for Breast Cancer

Placental and Umbilical Cord Blood as a Source of Stem Cells

Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2026-10-29)

Prior authorization required

Prior authorization required in some cases

Prior authorization required

Does Ambetter require prior authorization for 86817?

Does Anthem BCBS require prior authorization for 86817?

Does Blue Shield of California require prior authorization for 86817?

Does Coordinated Care require prior authorization for 86817?

What insurance policy changes affect CPT 86817?

Which payers have updated policy for CPT 86817?

How do I get notified when CPT 86817 policy changes?

Why do payers change policies for CPT 86817?