Hematopoietic Cell Transplantation for Aplastic Anemia and Other Bone Marrow Failure Syndromes — CPB 0627 | AETNA Coverage Update

Aetna modified CPB 0627 for hematopoietic cell transplantation for aplastic anemia and other bone marrow failure syndromes, effective December 12, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated this coverage policy governing allogeneic and autologous hematopoietic cell transplantation (HCT) for bone marrow failure conditions. The policy directly affects CPT codes 38230, 38240, 38232, and 38241, along with HCPCS code S2150. If your organization bills transplant services for severe aplastic anemia, Fanconi's anemia, Diamond-Blackfan anemia, paroxysmal nocturnal hemoglobinuria (PNH), or pure red cell aplasia under Aetna plans, CPB 0627 in the Aetna system governs your coverage.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Hematopoietic Cell Transplantation for Aplastic Anemia and Other Bone Marrow Failure Syndromes
Policy Code	CPB 0627
Change Type	Modified
Effective Date	December 12, 2025
Impact Level	High
Specialties Affected	Hematology/Oncology, Transplant Surgery, Bone Marrow Transplant Programs
Key Action	Audit documentation against Aetna's specific lab thresholds before billing CPT 38240 or requesting prior auth

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Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

The Aetna hematopoietic cell transplantation coverage policy draws a sharp line: allogeneic transplants are covered for the right indications with the right documentation. Autologous transplants are not.

Medical necessity under CPB 0627 hinges on whether the transplanting institution has its own published selection criteria. If it does, Aetna defers to those criteria for allogeneic HCT using CPT 38240 and CPT 38230. That's actually a practical pathway for major transplant centers with established protocols.

When institutional criteria don't exist, Aetna applies its own thresholds. These are specific, lab-value-driven requirements — not loose clinical judgment calls. Your documentation must match the numbers.

Severe aplastic anemia requires at least three of these four findings:

Three out of four. Not two. Get the lab values in the record.

Pure red cell aplasia requires both of these:

#	Covered Indication Copy
1	Bone marrow cellularity less than 25%
2	Reticulocyte count less than 1% or less than 20 × 10⁹/L (corrected for hematocrit)

Other covered conditions carry their own triggers. Diamond-Blackfan anemia requires corticosteroid refractoriness. Fanconi's anemia requires severe bone marrow failure, myelodysplastic syndrome, or acute myelogenous leukemia. PNH requires ongoing transfusion requirements and a suitable HLA-matched donor — CPT codes 86813, 86817, and 86821 cover the HLA typing work supporting that matching process.

Congenital dyserythropoietic anemia is also covered when the member is transfusion-dependent and has failed both interferon alfa and splenectomy. This is a narrow set of conditions, but each one has a defined clinical trigger.

Prior authorization almost certainly applies for transplant-level procedures under Aetna commercial plans. Confirm your prior auth requirements for CPT 38240 and HCPCS S2150 before scheduling. A claim denial on a transplant case is not a small write-off — these are high-cost episodes.

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Aetna Hematopoietic Cell Transplantation Exclusions and Non-Covered Indications

Autologous HCT is the hard wall in this coverage policy. Aetna classifies autologous hematopoietic cell transplantation as experimental, investigational, or unproven for every indication in CPB 0627. That means CPT 38232 (autologous bone marrow harvest) and CPT 38241 (autologous HPC transplantation) will not be covered for severe aplastic anemia, Diamond-Blackfan anemia, Fanconi's anemia, PNH, or pure red cell aplasia.

Aetna's reasoning: effectiveness hasn't been established for these indications. You can disagree with the clinical rationale, but the coverage policy is clear. Don't submit CPT 38241 for these diagnoses expecting reimbursement. It won't come.

If your program is treating any of these conditions with autologous transplant under a clinical trial, that's a separate billing pathway. Talk to your compliance officer before billing — the standard CPB 0627 route is closed.

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Coverage Indications at a Glance

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Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

The effective date of December 12, 2025 is already here. If you haven't reviewed your workflows against CPB 0627, do it now.

Copy Action Items

If your billing team handles a mix of commercial Aetna and Aetna Medicare Advantage plans, verify whether CPB 0627 applies uniformly or whether plan-specific riders modify these criteria. When you're not sure, loop in your compliance officer before the authorization process starts.

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CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0627

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, harvest

Not Covered / Experimental Codes

Code	Type	Description	Reason Copy
38232	CPT	Bone marrow harvesting for transplantation; autologous	Autologous HCT is experimental/investigational for all indications in CPB 0627
38241	CPT	Hematopoietic progenitor cell (HPC); autologous transplantation	Autologous HCT is experimental/investigational for all indications in CPB 0627

Other CPT Codes Related to CPB 0627

These codes appear in the policy as clinically related. They support documentation, pre-transplant workup, and related procedures.

Bone Marrow and Stem Cell Services (CPT 38204–38215)

Splenectomy Codes (Related to Congenital Dyserythropoietic Anemia Criteria)

Blood Count Codes (CPT 85004–85055)

Compatibility Testing Codes

Interferon Alfa HCPCS Codes (Related to Congenital Dyserythropoietic Anemia Criteria)

Code	Description Copy
J9212	Injection, interferon alfacon-1, recombinant, 1 microgram
J9213	Injection, interferon, alfa-2a, recombinant, 3 million units
J9214	Injection, interferon, alfa-2b, recombinant, 1 million units

Note on ICD-10-CM Codes: CPB 0627 does not list specific ICD-10-CM diagnosis codes. Work with your coding team to assign the appropriate diagnosis codes for severe aplastic anemia, Diamond-Blackfan anemia, Fanconi's anemia, PNH, pure red cell aplasia, and congenital dyserythropoietic anemia from the current ICD-10-CM code set.

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