CommercialCoverageHigh impact
Stem Cells for Hematopoietic Cell Transplant (CPB 0190, reviewed 2026-03-27)
Aetna·Hematology, Oncology, Pediatrics +2 more·Medical Policy
Effective date
Mar 27, 2026
We identified it
Aug 17, 2026
Summary
This is a foundational Aetna policy establishing medical necessity criteria for stem cell harvesting, testing, and transplantation procedures for hematopoietic cell transplant. The policy covers donor compatibility testing, umbilical cord blood stem cells as an alternative to bone marrow, stem cell boosting for graft failure, and Omidubicel-onlv (Omisirge), while explicitly excluding experimental procedures including mesenchymal stromal cell co-transplantation, certain imaging devices, and ex-vivo expanded umbilical cord blood transplantation. Billing teams must ensure claims align with covered versus non-covered indications and apply proper procedure codes.
Action Required
By 2026-03-27, billing team must: (1) Configure billing system to distinguish covered stem cell procedures (38204, 38205, 38206, 38207-38215, 38230, 38240, 38243, S2140, S2142, S2150) from non-covered experimental procedures (mesenchymal stromal cells co-transplantation, CPT 0901T Portomar access device, ex-vivo expanded cord blood); (2) Ensure claims for stem cell procedures include required ICD-10 codes (Z52.001, Z52.3 for donor identification; specific malignancy or condition codes for recipients); (3) Flag claims using excluded codes (0901T, mesenchymal stromal cell procedures, ELISPOT assays) for denial and provider education; (4) Configure system to require prior authorization verification before processing allogeneic stem cell harvesting, bone marrow harvesting, or transplantation codes; (5) For umbilical cord blood claims, verify recipient has documented malignancy and cord blood compatibility match before allowing S2140, S2142 billing; (6) Update provider documentation requirements to confirm donor relationship (first-degree or second-degree family members only) for allogeneic procedures; (7) Cross-reference CPB 1032 for Omidubicel-onlv (Omisirge) medical necessity prior to payment. Claims lacking proper prior auth, donor relationship documentation, or using non-covered experimental codes will be denied.