Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma (CPB 0494, reviewed 2026-08-03)

By 2026-08-03: Billing team must implement the following: (1) Update billing system to require prior authorization for CPT codes 38205, 38206, 38230, 38232, 38240, 38241, 86813, 86817, 86821, and HCPCS code S2150 for NHL cases. (2) Ensure claims include appropriate ICD-10 codes (C82.00-C96.9) confirming NHL diagnosis. (3) Verify patient meets medical necessity criteria before claim submission: relapsed/refractory disease OR first remission with high-risk histology (lymphoblastic, Burkitt's, mediastinal B-cell, mantle cell, high-grade DLBCL), evidence of chemotherapy response, and no serious organ dysfunction. (4) Flag all tandem autologous (auto-auto) or auto-allo transplant requests as experimental/investigational—these require medical review and should NOT be billed as covered services without explicit payer approval. (5) For allogeneic transplants, confirm donor eligibility (haploidentical to fully HLA-matched related, well-matched unrelated per NMDP criteria, or cord blood matched 4/6 HLA antigens). (6) Route claims lacking required documentation to providers for completion before submission. Failure to follow these requirements will result in claim denials. Contact Aetna medical management for case-by-case review of borderline eligibility scenarios.