CommercialPrior AuthMedium impact
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia (CPB 0674, reviewed 2025-12-23)
Aetna·Hematology, Oncology, Transplant Surgery +1 more·Medical Policy
Effective date
Dec 23, 2025
We identified it
Aug 17, 2026
Summary
Aetna's updated CPB 0674 (effective 2025-12-23) clarifies coverage for allogeneic hematopoietic cell transplantation in chronic myelogenous leukemia (CML), requiring either compliance with transplanting institution's written eligibility criteria OR documented failure/resistance/intolerance to tyrosine kinase inhibitors (imatinib, dasatinib, nilotinib) in patients without serious organ dysfunction. Autologous transplantation remains non-covered (experimental/investigational) for CML under all circumstances.
Action Required
By 2025-12-23: Billing team must implement the following in the billing system and claims review process: (1) For CPT codes 38205, 38230, 38240, and 38242 (allogeneic transplant procedures): Require prior authorization documentation confirming either the transplanting institution's written eligibility criteria OR evidence of TKI failure/resistance/intolerance (imatinib, dasatinib, or nilotinib) plus confirmation of no serious organ dysfunction. (2) Reject claims for CPT 38206, 38232, and 38241 (autologous transplant codes) for CML diagnoses (C92.10, C92.11) as non-covered. (3) Update claim scrubbing rules to flag any autologous transplant claims for CML with a denial notice citing experimental/investigational status. (4) Train billing and prior authorization staff on the new TKI resistance documentation requirements. Failure to implement prior authorization requirements will result in claim denials. Update encounter templates and prior authorization request forms to require providers to document TKI therapy history and response/resistance/intolerance status.