Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia — CPB 0674 | AETNA Coverage Update

Aetna modified CPB 0674 governing hematopoietic cell transplantation for chronic myelogenous leukemia, effective January 5, 2026. Here's what billing teams need to act on now.

Aetna, a CVS Health company, updated CPB 0674 to clarify allogeneic transplant coverage for CML under CPT codes 38205, 38230, 38240, and 38242. The policy draws a hard line: allogeneic transplantation can meet medical necessity, but autologous transplantation is experimental under all circumstances. If your team bills for bone marrow or stem cell services in oncology, this coverage policy change deserves a close look before you submit another claim.

Quick-Reference Table

Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2026

The Aetna hematopoietic cell transplantation coverage policy for CML runs on a two-track system. Allogeneic transplantation can be covered. Autologous transplantation cannot. Understanding which track your patient is on determines everything about how you bill and what you submit for prior authorization.

For allogeneic HCT to meet medical necessity, Aetna applies a tiered standard. If the transplanting institution has written eligibility criteria, the member must meet those criteria. That's the first track. If the institution has no written criteria, Aetna falls back on a clinical standard: the member must have failed, developed resistance to, or become intolerant of tyrosine kinase inhibitors—specifically imatinib, dasatinib, or nilotinib. The member must also have no serious organ dysfunction, based on the transplanting institution's evaluation.

This matters operationally. Your claim for CPT 38240 (allogeneic HPC transplantation per donor) or CPT 38230 (bone marrow harvesting, allogeneic) lives or dies on whether you can document one of those two pathways. If the institution has written criteria, attach them. If it doesn't, you need documented TKI failure or intolerance.

Prior authorization is standard for transplant-level procedures with Aetna. Before billing CPT 38205, 38230, 38240, or 38242 for a CML patient, confirm prior auth is in place. A claim denial on a transplant case creates serious reimbursement exposure—these are high-cost procedures, and a denial without prior auth on file is very difficult to recover.

Aetna HCT for CML Exclusions and Non-Covered Indications

This is where the policy is unambiguous, and billing teams should take that seriously. Aetna classifies autologous hematopoietic cell transplantation as experimental, investigational, or unproven for CML under all circumstances. Not "sometimes not covered." Not "covered with additional criteria." Under all circumstances.

That means CPT 38206 (autologous blood-derived HPC harvesting), CPT 38232 (autologous bone marrow harvesting), and CPT 38241 (autologous HPC transplantation) will not be reimbursed for CML patients under CPB 0674. Submitting these codes for a CML diagnosis against an Aetna plan will generate a denial. There is no appeal pathway based on medical necessity for this indication—the policy excludes it categorically.

The clinical rationale is that effectiveness for autologous transplantation in CML has not been established. That's Aetna's stated reason. From a billing standpoint, the reason doesn't change your action: don't bill autologous transplant codes for CML under this payer.

Coverage Indications at a Glance

Aetna HCT for CML Billing Guidelines and Action Items 2026

The effective date of January 5, 2026 means this coverage policy is already active. If you haven't reviewed your CML transplant billing workflows against this updated policy, do it now.

CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation for CML Under CPB 0674

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental CPT Codes

Covered HCPCS Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

Both C92.10 and C92.11 are applicable diagnosis codes under CPB 0674. Your medical necessity documentation and clinical narrative should match the specific CML status reflected by the ICD-10 code you submit. Submitting C92.11 (in remission) alongside a claim for urgent allogeneic transplantation due to TKI failure will invite scrutiny—make sure the clinical documentation and the diagnosis code tell the same story.