Hematopoietic Cell Transplantation for Selected Leukemias — CPB 0640 | AETNA Coverage Update

TL;DR: Aetna modified CPB 0640 governing hematopoietic cell transplantation (HCT) for selected leukemias, effective December 17, 2025. If your team bills CPT 38240, 38241, or 38242 for Aetna members with ALL, AML, CMML, or related leukemias, review your documentation and prior authorization workflows now.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Hematopoietic Cell Transplantation for Selected Leukemias
Policy Code	CPB 0640
Change Type	Modified
Effective Date	December 17, 2025
Impact Level	High
Specialties Affected	Hematology/Oncology, Bone Marrow Transplant Programs, Hospital Billing, Blood Banking
Key Action	Audit your HCT authorization requests and ICD-10 coding against the updated indication-level criteria before submitting new claims

---

Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

The Aetna hematopoietic cell transplantation coverage policy under CPB 0640 covers a broad set of leukemia indications — but the criteria are tightly defined. Each leukemia type gets its own set of transplant-type rules. Getting this wrong means a claim denial on a six-figure case.

The baseline rule is that Aetna defers to the transplanting institution's own selection criteria. If your institution has documented selection criteria, Aetna treats that as the primary gate. Where no institutional criteria exist, Aetna's own criteria apply. That distinction matters for your prior authorization documentation — you need to show which set of criteria governed the decision.

Acute Lymphocytic Leukemia (ALL) — CPT 38240, 38242

Allogeneic HCT (CPT 38240) is medically necessary for ALL when the member meets the transplanting institution's selection criteria. Without institutional criteria, Aetna covers allogeneic HCT for ALL — including primary refractory ALL — except for members in refractory relapse. Refractory relapse means the patient is in relapse and unresponsive to three or more months of adequate chemotherapy. That exclusion is a hard stop.

Non-myeloablative allogeneic HCT — sometimes called a mini-allograft or reduced intensity conditioning transplant — is covered for ALL only when the member has no persistent disease. Patients with persistent disease are explicitly excluded from mini-allograft coverage. Document the absence of persistent disease in your prior auth submission or expect a denial.

Autologous HCT (CPT 38241) is not covered for ALL. The ICD-10 codes C91.0 and C91.1 carry a specific note in the policy: "not covered for autologous transplantation." If your billing team is submitting 38241 with an ALL diagnosis code, stop and review those claims now.

Acute Myelogenous Leukemia (AML) — CPT 38240, 38241

Autologous HCT (CPT 38241) is medically necessary for AML when institutional criteria are met. Without those criteria, Aetna covers autologous HCT for AML in any remission stage or in relapsed AML if responsive to intensified induction chemotherapy. The one exclusion: autologous HCT as first-line treatment for AML is not covered.

Allogeneic HCT — ablative or mini-allograft — is covered for AML under any one of three indications:

#	Covered Indication Copy
1	The member relapsed after a prior autologous HCT and can medically tolerate the procedure.
2	Poor-risk to intermediate-risk AML in remission.
3	Primary refractory AML — defined as leukemia that doesn't achieve complete remission after conventional dose chemotherapy.

Repeat allogeneic HCT for AML is covered when the first transplant failed due to primary graft failure, failure to engraft, or when the member relapsed after a prior HCT. You need documentation of what caused the first transplant to fail — this is exactly the kind of record that gets requested in a medical review, and missing it will stall your reimbursement.

CMML and JMML

Allogeneic HCT — ablative or non-myeloablative — is medically necessary for chronic myelo-monocytic leukemia (CMML) and juvenile myelo-monocytic leukemia (JMML) when a matched or haploidentical donor is available. That donor availability requirement is explicit. Document donor matching status in your prior authorization packet.

Repeat allogeneic HCT is covered for CMML and JMML due to primary graft failure or failure to engraft.

Other Covered Leukemia Indications

#	Covered Indication Copy
1	T-cell prolymphocytic leukemia: Allogeneic HCT (ablative or non-myeloablative) is covered.
2	Acute promyelocytic leukemia (APL): HCT — allogeneic or autologous — as consolidation therapy in second or subsequent remission is covered.
3	Richter syndrome (RS): Allogeneic HCT is covered when institutional selection criteria are met. Without those criteria, Aetna has its own criteria — check the full CPB 0640 text for the complete RS language, since the policy summary was truncated at that point.

The HLA typing codes — CPT 86813, 86817, and 86821 — and transplant preparation and harvesting codes (CPT 38205–38215) are part of the covered code set when selection criteria are met. These diagnostic and preparation procedures support the transplant workflow. Make sure your billing guidelines for pre-transplant workup include these codes if your program bills them separately.

---

Aetna Hematopoietic Cell Transplantation Exclusions and Non-Covered Indications

The clearest exclusion in this coverage policy is autologous HCT for ALL. Full stop — ICD-10 codes C91.0 and C91.1 are explicitly flagged as not covered for autologous transplantation.

For AML, autologous HCT as first-line treatment is not covered. If a member hasn't received prior chemotherapy and your team bills 38241 for AML as initial treatment, expect a claim denial.

For mini-allograft in ALL, any member with persistent disease is excluded. This is a clinical documentation issue as much as a billing one — your prior auth team needs the treating physician to document disease status explicitly.

The policy also carves out members in refractory relapse for ALL allogeneic HCT. If a member is in relapse and has been on adequate chemotherapy for more than three months without response, allogeneic HCT is not covered under Aetna's criteria. That's a situation where your compliance officer and the transplant team need to align before submitting an authorization request.

---

Coverage Indications at a Glance

---

Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

This policy is high-exposure. HCT cases routinely generate six-figure claims. A documentation gap or wrong transplant type on the authorization request doesn't just delay payment — it triggers a denial you may not recover on appeal.

Here's what your team needs to do before or immediately after the December 17, 2025 effective date:

Copy Action Items

---

CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0640

Covered CPT Codes (When Selection Criteria Are Met)

Note: In the source policy, codes 38205–38215 appear under a coverage group labeled "Killer-cell immunoglobulin-like receptor (KIR) genotyping." That label reflects Aetna's internal coverage grouping — it does not mean these codes are KIR genotyping procedures. These are transplant harvesting and preparation codes, as the standard CPT descriptions below reflect.

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

Key ICD-10-CM Diagnosis Codes

Note: The full policy lists 115 ICD-10-CM codes. Pull the complete code list from the CPB 0640 source document at app.payerpolicy.org/p/aetna/0640 to build your internal charge capture edits.

---