Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma — CPB 0494 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0494 governing hematopoietic cell transplantation (HCT) for non-Hodgkin's lymphoma, with an effective date of December 11, 2025. Here's what changes for billing teams.

This update to the Aetna NHL transplant coverage policy touches CPT codes 38205, 38206, 38230, 38232, 38240, and 38241 — the core harvesting and transplantation procedure codes — along with HCPCS code S2150 and HLA typing codes 86813, 86817, and 86821. If your facility bills hematopoietic cell transplantation for NHL patients covered by Aetna, you need to review your medical necessity documentation and prior authorization workflows against the updated criteria now.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma
Policy Code	CPB 0494
Change Type	Modified
Effective Date	December 11, 2025
Impact Level	High
Specialties Affected	Hematology/Oncology, Bone Marrow Transplant Programs, Hospital Revenue Cycle
Key Action	Audit prior authorization submissions and medical necessity documentation against updated autologous and allogeneic HCT criteria before billing CPT 38240 or 38241

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Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

CPB 0494 Aetna covers two distinct transplant pathways for NHL: autologous and allogeneic. The criteria differ meaningfully between the two. Mixing them up in a prior authorization request is a fast path to a claim denial.

Autologous HCT: What Aetna Requires

Aetna considers autologous HCT — billed under CPT 38206 (blood-derived progenitor cell harvesting, autologous) and CPT 38241 (autologous transplantation) — medically necessary for relapsed or primary refractory NHL when all three conditions are met:

#	Covered Indication Copy
1	The patient has relapsed or refractory NHL.
2	The disease is chemotherapy responsive, defined as at least a 50% decrease in tumor burden (complete or partial remission).
3	No serious organ dysfunction exists, based on the transplanting institution's evaluation.

The definition of "responsive" matters here. Aetna defines responsiveness as a complete or partial remission. Partial remission means at least a 50% reduction in tumor burden. Document that number explicitly in your medical records. Don't leave the reviewer to infer it.

Refractory disease means failure to attain a complete or partial response. It can be primary (failure to respond to initial therapy) or secondary (initial response, then failure after relapse). The distinction matters for the chart documentation supporting your medical necessity criteria.

There's an exception on chemoresistant disease. Aetna will consider autologous HCT medically necessary for chemoresistant, widely metastatic relapsed disease if allogeneic transplantation can't be offered. This is a narrow carve-out. If you're billing for this scenario, your documentation needs to explicitly address why allogeneic transplant was ruled out.

Aetna also recognizes first clinical remission cases for specific high-risk subtypes. These include lymphoblastic NHL, Burkitt's lymphoma, mediastinal B-cell lymphoma, mantle cell lymphoma, high-risk diffuse large B-cell lymphoma, and other NHLs associated with poor prognosis. Clinical review drives these decisions. Get that documentation tight before submitting prior auth.

Allogeneic HCT: Different Criteria, Same Scrutiny

Allogeneic HCT — billed under CPT 38205 (blood-derived progenitor cell harvesting, allogeneic) and CPT 38240 (allogeneic transplantation per donor) — carries its own medical necessity criteria. Aetna covers it for relapsed NHL, including post-autologous HCT relapse, and for primary refractory NHL across all grades (low, intermediate, high).

Three criteria must all be met in the absence of a protocol:

#	Covered Indication Copy
1	The patient has relapsed or refractory NHL.
2	The patient has an appropriate donor: haploidentical to fully HLA-matched related donor, a well-matched unrelated donor meeting National Marrow Donor Program (NMDP) criteria, or single or double cord blood matched for at least 4 of 6 HLA ABDR antigens.
3	No serious organ dysfunction, per the transplanting institution's evaluation.

HLA typing codes 86813 (HLA typing, A, B, or C, multiple antigens), 86817 (DR/DQ, multiple antigens), and 86821 (lymphocyte culture, mixed) are covered when selection criteria are met. These codes support the donor matching requirement. Don't bill them in isolation — they need to connect to the allogeneic transplant authorization.

Aetna also covers non-myeloablative allogeneic HCT ("mini-transplant," reduced intensity conditioning transplant) under this policy. The reimbursement pathway and documentation requirements follow the same allogeneic criteria. First clinical remission cases are also considered for lymphoblastic NHL, Burkitt's, mediastinal B-cell lymphoma, mantle cell lymphoma, and other poor-prognosis NHLs.

This is a complex policy with a lot of moving parts. If your transplant program doesn't have a dedicated billing specialist who works these cases daily, talk to your compliance officer before the December 11 effective date.

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Aetna HCT for NHL Exclusions and Non-Covered Indications

Aetna considers autologous HCT experimental, investigational, or unproven when specific contraindications are present. Two contraindications apply:

#	Excluded Procedure Copy
1	Co-morbid diseases — the policy cites uncontrolled hypertension as an example.
2	Evidence of serious organ dysfunction.

These aren't soft guidelines. If the transplanting institution's evaluation documents serious organ dysfunction, Aetna will not cover autologous HCT under CPT 38241. A claim submitted without addressing these contraindications will be denied.

The real issue here is documentation. Organ dysfunction is flagged at the institution level, and Aetna defers to that evaluation. Your authorization package needs to clearly show the institution's findings — not just a checkbox, but actual clinical data.

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Coverage Indications at a Glance

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Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

These are your specific action items before and after the December 11, 2025 effective date.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0494

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
S2150	HCPCS	Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications

Other CPT Codes Related to CPB 0494

These codes are referenced in the policy but are not listed in the covered-with-criteria group. Verify coverage and billing guidelines on a case-by-case basis.

Other HCPCS Codes Related to CPB 0494

Code	Type	Description Copy
Q0083	HCPCS	Chemotherapy administration
Q0084	HCPCS	Chemotherapy administration
Q0085	HCPCS	Chemotherapy administration

Key ICD-10-CM Diagnosis Codes

Code Range	Description Copy
C82.00–C96.9	Malignant neoplasm of lymphoid, hematopoietic, and related tissue (excluding Hodgkin's disease)

This ICD-10 range covers the full scope of NHL diagnoses applicable under this policy. Make sure your diagnosis codes link to the correct subtype within the range — specificity matters on these claims. A generic C85.90 (NHL, unspecified) when the record clearly supports a mantle cell lymphoma diagnosis (C83.10) leaves clinical nuance on the table and gives reviewers less to work with.

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