Hematopoietic Cell Transplantation for Multiple Myeloma — CPB 0497 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0497 governing hematopoietic cell transplantation (HCT) for multiple myeloma, effective December 11, 2025. Here's what billing teams need to act on now.

This update to the Aetna multiple myeloma coverage policy touches autologous, allogeneic, and tandem transplant eligibility criteria — along with a newly covered assessment for circulating plasma cells. The primary codes affected include CPT 38240 and 38241 for transplantation, CPT 38205 and 38206 for cell harvesting, and HCPCS S2150 for stem cell harvest. If your practice or facility bills HCT for myeloma, this update requires a close review before December 11, 2025.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Hematopoietic Cell Transplantation for Multiple Myeloma
Policy Code	CPB 0497
Change Type	Modified
Effective Date	December 11, 2025
Impact Level	High
Specialties Affected	Hematology/Oncology, Bone Marrow Transplant Programs, Radiation Oncology, Hospital Billing
Key Action	Audit your prior auth workflows and documentation for all HCT indications against updated selection criteria before December 11, 2025

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Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

CPB 0497 Aetna covers HCT for multiple myeloma across three transplant types — autologous, allogeneic, and tandem — but the medical necessity criteria for each are distinct. Getting one wrong means a claim denial. Know which set of rules applies before you submit.

Autologous HCT (CPT 38241, 38232, HCPCS S2150)

Aetna considers autologous HCT medically necessary for multiple myeloma (MM), amyloidosis, and POEMS syndrome when the transplanting institution's written eligibility criteria are met. That's the easy path — if your institution has a documented protocol, lead with that in your prior auth submission.

When no institutional protocol exists, all four of these criteria must be met:

That last exclusion matters. MGUS patients are explicitly out, even if they look like reasonable transplant candidates clinically. Flag this during your pre-authorization review.

Second autologous transplants for relapsed disease are covered — and this policy is clear that a second course following relapse is not the same as tandem transplantation. Aetna will cover a second autologous transplant for MM or POEMS syndrome when the disease responded with a durable complete or partial remission after the first transplant, and has now relapsed. Document that prior remission carefully. It's the key to reimbursement on these cases.

Allogeneic HCT (CPT 38240, 38205, HCPCS S2150)

Allogeneic HCT follows a similar protocol-first structure. When an institutional protocol exists, meeting those eligibility criteria satisfies medical necessity.

Without a protocol, only two criteria must both be met:

#	Covered Indication Copy
1	Adequate major organ function per the transplanting institution's evaluation
2	Early relapse — defined as less than 24 months — after primary therapy that included an autologous HCT (for MM patients only)

The 24-month window is a hard line. Document the date of the prior autologous transplant and the date of confirmed relapse. If you can't show that gap is under 24 months, the allogeneic claim won't survive review.

Non-myeloablative allogeneic HCT — often called a mini-transplant or reduced intensity conditioning transplant — also qualifies as medically necessary for MM and POEMS syndrome, as long as the member is eligible for conventional allografting. This is a useful pathway for older or less fit patients, but the eligibility documentation still needs to mirror the full allograft criteria.

Tandem Transplants (CPT 38240, 38241, HCPCS S2150)

Tandem (sequential) transplants are covered when institutional protocol criteria are met. Outside of a protocol, Aetna requires all the autologous criteria above, plus two additional conditions:

#	Covered Indication Copy
1	The member has active myeloma
2	Both transplants are planned within a six-month window

That six-month timeline is not soft guidance. If the gap between first and second transplant exceeds six months, Aetna will not treat this as a covered tandem procedure. Build that timeline check into your prior auth process.

Circulating Plasma Cell Assessment (CPT 38205, 38206)

This is the genuinely new addition in the December 11, 2025 update. Aetna now considers assessment for circulating plasma cells medically necessary for prognostication in newly diagnosed MM patients. Aetna's policy notes this does not have a specific CPT code — you'll use codes associated with hematopoietic progenitor cell harvesting (CPT 38205 for allogeneic collection, CPT 38206 for autologous) depending on context, but check with your compliance officer on the best mapping before billing this service.

This coverage change reflects the growing use of circulating plasma cell assessment as a prognostic tool at diagnosis. From a billing standpoint, this is net positive — it opens a reimbursement path that didn't exist in prior versions of this policy.

Prior authorization requirements apply to HCT procedures under this coverage policy. Confirm your authorization request includes transplant type, institutional protocol documentation (or individual eligibility criteria), and organ function evaluation documentation.

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Aetna HCT for Multiple Myeloma — Exclusions and Non-Covered Indications

One clear experimental designation in this update: natural killer (NK) cell-enhanced autologous stem cell transplantation (ASCT) for MM is considered experimental, investigational, or unproven. Aetna's position is that effectiveness has not been established.

If your transplant program is running NK cell-enhanced ASCT protocols or clinical trials, don't expect commercial reimbursement through Aetna under this policy. Claims billed under CPT 38241 or HCPCS S2150 that include NK cell augmentation will likely face denial under the experimental designation.

The exclusion criteria for single and tandem transplantation also create non-covered territory. Any of the following disqualifies a patient from coverage:

#	Excluded Procedure Copy
1	Inadequate cardiac, renal, pulmonary, or hepatic function (the policy summary was truncated here, but organ function failure is explicitly listed as exclusionary)
2	Indolent myeloma, smoldering myeloma, or MGUS (for autologous transplants without an institutional protocol)
3	Prior extensive chemotherapy or radiation beyond the defined thresholds

POEMS syndrome is a covered indication across all three transplant types. Waldenstrom macroglobulinemia (ICD-10 C88.0) appears in the diagnosis code list, though the primary indications for coverage are MM and POEMS.

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Coverage Indications at a Glance

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Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

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If your facility handles complex or high-volume HCT cases, loop in your compliance officer and transplant billing consultant before the December 11, 2025 effective date. The criteria distinctions between transplant types — especially around protocols, relapse timing, and second transplants — create real claim denial exposure.

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CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0497

Covered CPT Codes — Transplantation and Harvesting (When Selection Criteria Are Met)

Additional CPT Codes Related to CPB 0497

HCPCS Codes

Key ICD-10-CM Diagnosis Codes

Code	Description Copy
C88.0	Waldenstrom macroglobulinemia

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