Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)

By August 6, 2026: (1) Billing team must update billing system edits to require documentation of response to induction therapy (CR/PR/MR/SD per INRC criteria) before authorizing CPT 38206, 38232, or 38241 for neuroblastoma cases. (2) Configure system to deny claims for CPT 38205, 38240, 86813, 86817, 86821 when coded for neuroblastoma (allogeneic transplant is experimental). (3) Update prior authorization workflows to require clinical criteria verification: for tandem HCT (common high-risk group), for single HCT (special high-risk groups with specified Stage/age/MYCN/histology), and for relapsed disease (chemosensitivity confirmation required). (4) Implement edits to reject CPT 38206/38232/38241 claims if progressive disease (PD) is documented during or at end of induction. (5) For Ewing's sarcoma, PNET, ependymoma, retinoblastoma, and Wilms' tumor claims: verify autologous transplant is used (not allogeneic, which is experimental). (6) Configure soft deny for HCPCS M0075 and S2107 (cellular therapy/adoptive immunotherapy are experimental). (7) Providers must document disease stage, age at diagnosis, MYCN status, histology, and chemotherapy response on all HCT authorization requests for these pediatric oncology cases. Failure to implement will result in claim denials and compliance audit findings.