What insurance policy changes affect code T86.5?

There are 10 tracked policy changes affecting code T86.5, including updates from Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code T86.5?

Payers that have issued tracked updates for code T86.5 include: Aetna.

How do I get notified when code T86.5 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code T86.5. 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 code T86.5?

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

T86.5 Insurance Policy Changes

ICD-10 T86.5 is officially defined as "Complications of stem cell transplant." code T86.5 is referenced in 10 tracked payer policy changes from Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code T86.5 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Effective Feb 27, 2026Medium impact
Narsoplimab-wuug (Yartemlea) (CPB 1099, reviewed 27-2026-04)
Aetna has established a new clinical policy (CPB 1099) for Narsoplimab-wuug (Yartemlea), a monoclonal antibody for treating hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA) in patients age 2+. The policy requires precertification for all claims, strict diagnostic criteria including platelet counts <150,000/µL and microangiopathic hemolysis evidence, ADAMTS13 activity ≥10%, and prohibits concurrent use with complement inhibitors or defibrotide.
Aetna · Identified Oct 28, 2026Medium impact
ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-10-27)
Aetna's Clinical Policy Bulletin 0780 considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP), and for distinguishing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA) from TTP in persons with overlapping features when the test will be used to inform treatment. CPT code 85397 is covered if selection criteria are met, and ICD-10 codes M31.10, M31.11, M31.19, R71.8, R74.02, R79.89 and T86.5 are covered if selection criteria are met. The policy lists many other indications, including hemolytic uremic syndrome and monitoring of liver diseases, as experimental, investigational or unproven because of insufficient evidence of clinical utility.
Aetna · Identified Oct 19, 2026Medium impact
Narsoplimab-wuug (Yartemlea) (CPB 1099, reviewed 2026-10-16)
Aetna's policy on Yartemlea (narsoplimab-wuug) applies to commercial medical plans, and precertification is required. Aetna considers Yartemlea medically necessary for hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA) in members 2 years of age or older when the diagnosis is confirmed, the drug is not used with another complement inhibitor or defibrotide, and ADAMTS13 activity is at least 10%. Continuation requires no unacceptable toxicity and a positive response, such as improved platelet levels and renal function, and all other indications are considered experimental, investigational, or unproven.
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 3, 2026Medium impact
Narsoplimab-wuug (Yartemlea) (CPB 1099)
Aetna has established a new coverage policy for Narsoplimab-wuug (Yartemlea) for treatment of hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA) in patients 2 years and older. The policy requires precertification for all claims and specifies strict clinical criteria including platelet count <150,000/μL, evidence of microangiopathic hemolysis, ADAMTS13 activity ≥10%, and prohibits concurrent use with other complement inhibitors or defibrotide.
Aetna · Identified Oct 1, 2026Medium impact
Donor Lymphocyte Infusion (CPB 0638, reviewed 2026-09-29)
Aetna considers donor lymphocyte infusion medically necessary for persons who have had a prior medically necessary allogeneic bone marrow or peripheral stem cell transplantation. Several uses are considered experimental, investigational, or unproven, including GCSF-stimulated donor lymphocyte infusions for relapsed disease, intrathecal donor lymphocyte infusion, modified donor lymphocytes, reduced-dose infusion for Epstein-Barr virus-related post-transplant lymphoproliferative disease, pre-transplant infusion of extracorporeal photochemotherapy-treated donor lymphocytes for solid organ transplant, and donor lymphocyte-derived natural killer cells for melanoma. The policy does not apply to FDA-approved chimeric antigen receptor therapy, which is addressed in CPB 0920 and CPB 0924.
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
ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-04-27)
Aetna considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP), and for distinguishing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA, also called transplant-associated TMA) from TTP in persons with overlapping features when the test will be used to inform treatment. Aetna considers the assay experimental, investigational, or unproven for the uses it lists because of insufficient evidence, including sepsis-associated thrombotic microangiopathy, hemolytic uremic syndrome, acute myelogenous leukemia, colorectal cancer survival, COVID-19, cerebral infarction, and ADAMTS13 mutation testing for non-cirrhotic portal hypertension.
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.
Aetna · Identified Aug 14, 2026Medium impact
Donor Lymphocyte Infusion (CPB 0638, reviewed 2025-11-12)
Aetna considers donor lymphocyte infusion (DLI) medically necessary for persons who have had a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation. Aetna considers these uses experimental, investigational, or unproven: GCSF-stimulated DLI for relapsed disease after allogeneic hematopoietic cell transplantation, intrathecal DLI, modified donor lymphocytes (such as depleted, expanded, T-cell depleted, CAR-modified or genetically modified cells), pre-transplant infusion of extracorporeal photochemotherapy-treated donor lymphocytes to prevent graft rejection after solid organ transplantation, reduced-dose DLI for Epstein-Barr virus-related post-transplant lymphoproliferative disease, and donor lymphocyte-derived natural killer cells for melanoma. The policy does not apply to FDA-approved CAR T therapy, which involves modification of autologous lymphocytes.

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Narsoplimab-wuug (Yartemlea) (CPB 1099, reviewed 27-2026-04)

ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-10-27)

Narsoplimab-wuug (Yartemlea) (CPB 1099, reviewed 2026-10-16)

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

Narsoplimab-wuug (Yartemlea) (CPB 1099)

Donor Lymphocyte Infusion (CPB 0638, reviewed 2026-09-29)

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

ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-04-27)

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

Donor Lymphocyte Infusion (CPB 0638, reviewed 2025-11-12)

What insurance policy changes affect code T86.5?

Which payers have updated policy for code T86.5?

How do I get notified when code T86.5 policy changes?

Why do payers change policies for code T86.5?