Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors — CPB 0496 | AETNA Coverage Update

Aetna modified CPB 0496 covering hematopoietic cell transplantation for childhood solid tumors, effective December 11, 2025. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its hematopoietic cell transplantation coverage policy for selected childhood solid tumors under CPB 0496 in the Aetna system. This policy governs autologous transplant billing for diagnoses including high-risk neuroblastoma, Ewing's sarcoma, Wilms' tumor, retinoblastoma, and several CNS tumors. The primary covered procedure codes are CPT 38206 and 38241 for autologous collection and transplantation, along with HCPCS S2150 for stem cell harvest. If your team bills these services for pediatric oncology patients, this policy update directly affects your claim submission and prior authorization workflows in 2025 and beyond.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors
Policy Code	CPB 0496
Change Type	Modified
Effective Date	December 11, 2025
Impact Level	High
Specialties Affected	Pediatric Oncology, Bone Marrow Transplant Programs, Hematology/Oncology, Radiation Oncology
Key Action	Audit active cases against updated medical necessity criteria before billing CPT 38241 or 38206 under any covered diagnosis

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Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

The central question in the Aetna hematopoietic cell transplantation coverage policy is whether autologous transplant is medically necessary — and Aetna's answer depends heavily on tumor type, disease stage, and molecular markers.

High-Risk Neuroblastoma

For neuroblastoma, Aetna covers autologous HCT under CPT 38241 when the member meets the transplanting institution's protocol selection criteria. In the absence of a protocol, three pathways to medical necessity exist.

First, autologous HCT is covered as primary treatment for Stage II or Stage III neuroblastoma when associated with more than 10 copies of the n-myc oncogene. Second, it's covered as primary treatment for Stage IV neuroblastoma, regardless of n-myc status. Third, it's covered as therapy for primary recurrent or refractory disease when conventional-dose therapy is unlikely to achieve durable remission.

Aetna defines "high-risk neuroblastoma" with specificity. That definition matters — it controls reimbursement for this entire category. The definition covers:

Document these molecular and histologic findings in the medical record before you submit. Missing n-myc amplification data is a predictable claim denial trigger under this policy.

Aetna also covers repeat autologous HCT (a second transplant) for patients with chemosensitive neuroblastoma who relapse after a first autologous transplant. And tandem (sequential) autologous transplantation — two transplants planned as part of a single treatment strategy — is covered for high-risk neuroblastoma when the member meets the criteria above. Tandem transplants are increasingly common in pediatric neuroblastoma protocols, so confirm your billing team knows to bill each transplant episode separately under CPT 38241 with the appropriate ICD-10-CM diagnosis codes.

Other Covered Solid Tumor Indications

The coverage policy extends autologous HCT coverage to five additional tumor types. Each has distinct medical necessity requirements:

Ewing's sarcoma family of tumors: Covered for relapsed or progressive, chemotherapy-sensitive disease that is not widely metastatic. "Not widely metastatic" is doing real work here — broadly metastatic Ewing's does not meet criteria. Map diagnoses to C40.00–C41.9 for bone primary sites or C49.x for soft tissue primaries.

Primitive neuroectodermal tumors (PNET), including medulloblastoma and pineoblastoma: Covered. No additional qualifier around chemo-sensitivity or disease status — these are covered without the relapse or progression requirement. This is notably broader than the Ewing's criteria.

Ependymoma: Covered only for members ineligible for radiotherapy. If radiation is an option, autologous HCT is not covered under this policy. Your authorization request needs documentation of radiation ineligibility — not just preference avoidance.

Extraocular retinoblastoma: Covered. Use ICD-10-CM C69.20–C69.22. Intraocular retinoblastoma is not addressed in the covered indications, so don't assume it qualifies.

Wilms' tumor: Covered for progressive or relapsed, chemosensitive disease. Use C64.1–C64.9 for kidney primary diagnoses.

Prior authorization requirements for these services should be confirmed directly with Aetna, as transplant services of this type typically require pre-authorization. If your transplant center doesn't already have a standard prior auth documentation package that captures stage, molecular markers, chemosensitivity, and protocol enrollment status, build one now. One incomplete submission wastes weeks.

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Aetna Hematopoietic Cell Transplantation Exclusions and Non-Covered Indications

This is where billing teams get burned. Several procedures related to HCT are explicitly excluded under CPB 0496.

Allogeneic transplantation for neuroblastoma is not covered. CPT 38240 (allogeneic HPC transplantation) and CPT 38205 (allogeneic stem cell harvesting) are listed in the covered code set, but the neuroblastoma indication specifically excludes these. The same applies to CPT 38230 (bone marrow harvesting for allogeneic use). Bill autologous codes (38206, 38241) for neuroblastoma — not allogeneic.

Adoptive cellular immunotherapy from haploidentical or matched donors is considered experimental, investigational, or unproven. HCPCS M0075 (cellular therapy) and HCPCS S2107 (adoptive immunotherapy, including tumor-infiltrating lymphocyte therapy) are specifically listed as not covered under this policy. Don't expect reimbursement for these under CPB 0496, and don't bundle them with a covered autologous transplant without a clear coverage pathway.

The takeaway: allogeneic approaches and immunotherapy-based strategies fall outside this coverage policy for these indications. If your clinical team is using these approaches, work with your compliance officer to identify whether another policy covers them or whether an advance beneficiary-style notice is appropriate before the effective date passes.

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Coverage Indications at a Glance

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Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

This policy has real financial exposure. HCT claims for pediatric oncology patients carry high dollar values and are closely scrutinized during claims review. Follow these steps before the effective date of December 11, 2025 passes.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0496

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental HCPCS Codes

Code	Type	Description	Reason Copy
M0075	HCPCS	Cellular therapy	Not covered for indications listed in CPB 0496
S2107	HCPCS	Adoptive immunotherapy (e.g., tumor-infiltrating lymphocyte therapy)	Not covered for indications listed in CPB 0496

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, harvest, transplantation

Key ICD-10-CM Diagnosis Codes

Note: The full ICD-10-CM list under CPB 0496 contains 137 codes. The table above reflects representative ranges from the policy data. Access the complete code list at app.payerpolicy.org/p/aetna/0496.

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