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

By December 11, 2025: (1) Billing team must implement pre-claim verification that allogeneic hematopoietic cell transplant cases document one of five approved indications (severe aplastic anemia, Diamond-Blackfan anemia, Fanconi's anemia, paroxysmal nocturnal hemoglobinuria, or pure red cell aplasia). (2) For severe aplastic anemia cases, require documentation confirming member meets AT LEAST 3 of 4 diagnostic criteria: bone marrow cellularity <25%, neutrophil count <0.5 x 10^9/L, reticulocyte count <1% or <20 x 10^9/L, and untransfused platelet count <20 x 10^9/L. (3) Update billing software rules to DENY claims for CPT 38232 (autologous bone marrow harvesting) and CPT 38241 (autologous HPC transplantation) for all indications listed in this policy—mark as investigational/non-covered. (4) Create denial response template citing medical policy CPB 0627 for autologous transplant rejections. (5) Flag all repeat allogeneic transplant claims (primary graft failure, rejection) for authorization verification. Providers and clinical staff should update transplant case documentation templates to include required diagnostic thresholds before claim submission. Failure to verify criteria will result in claim denials and rework.