Traditional MedicareCoverageMedium impact
Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin
Medicare/CMS - LCD·Oncology, Hematology, Transplant Surgery·Local Coverage Determination
Effective date
Apr 1, 2026
We identified it
Jul 28, 2026
Summary
This is a NEW Local Coverage Determination (LCD L39513) from Wellpoint Federal that establishes coverage criteria for allogeneic hematopoietic cell transplantation (bone marrow/stem cell transplant) in Medicare beneficiaries with primary refractory or relapsed Hodgkin lymphoma and Non-Hodgkin lymphoma of B-cell or T-cell origin. Effective April 1, 2026, this policy will require billing teams to verify patient eligibility, obtain prior authorization, and ensure proper documentation of lymphoma histology and treatment history before submitting transplant-related claims.
Action Required
By March 15, 2026: Billing and clinical teams must: (1) Review the full policy text at https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39513&ver=4 to identify specific coverage criteria, approved indications, and prior authorization requirements; (2) Update billing system documentation to flag all hematopoietic cell transplant claims for Medicare beneficiaries with lymphoma for mandatory prior authorization review before submission; (3) Train providers and clinical staff to document lymphoma histology (B-cell vs T-cell origin), prior treatment history, and primary refractory or relapsed status in medical records; (4) Establish internal workflow to route these claims to prior authorization team; (5) Update patient intake forms to identify potential transplant candidates. Effective April 1, 2026: Do not bill hematopoietic cell transplant services for Medicare beneficiaries without prior authorization confirmation. Claims submitted without meeting LCD L39513 coverage criteria will be denied. Contact Wellpoint Federal MAC for specific coding guidance if not included in policy detail.