Hematopoietic Cell Transplantation for Solid Tumors in Adults — CPB 0811 | AETNA Coverage Update

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Aetna modified CPB 0811 for hematopoietic cell transplantation in adult solid tumors, effective December 4, 2025. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its hematopoietic cell transplantation coverage policy under CPB 0811 Aetna system, classifying stem cell transplants — both autologous and allogeneic — as experimental, investigational, or unproven for 24 solid tumor types in adults. The full code set affected spans CPT codes 38204 through 38242, HCPCS codes S2142 and S2150, and 172 ICD-10-CM diagnosis codes. If your team bills hematopoietic stem cell transplantation (HCT) for any adult oncology indication, read this before submitting another claim.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Hematopoietic Cell Transplantation for Solid Tumors in Adults
Policy Code	CPB 0811
Change Type	Modified
Effective Date	December 4, 2025
Impact Level	High
Specialties Affected	Hematology/Oncology, Bone Marrow Transplant Programs, Hospital-Based Transplant Centers
Key Action	Audit all pending and scheduled HCT claims tied to adult solid tumor diagnoses before submitting — every one of these will deny under the current coverage policy

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Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

CPB 0811 covers one thing in this context: what Aetna will not pay for. There are no covered indications for HCT in adult solid tumors under this policy. The policy draws a hard line — autologous and allogeneic transplants, ablative and non-myeloablative conditioning, all fail the medical necessity threshold for every solid tumor type listed.

The Aetna hematopoietic cell transplantation coverage policy does not distinguish between conditioning intensity. You might think a non-myeloablative "mini-allograft" for a borderline case has a better shot. It does not. Aetna treats reduced-intensity conditioning transplants the same as full ablative regimens for these indications. See CPB 0634 for Aetna's separate non-myeloablative policy — but don't expect a different outcome for the tumor types listed here.

Prior authorization requests for CPT 38240 (allogeneic transplantation) or CPT 38241 (autologous transplantation) against any of the 24 solid tumor diagnoses will not result in approval. Submit the prior auth if your process requires documentation, but your compliance officer should know in advance that Aetna's position is categorical on these indications. If you're billing for an inpatient transplant episode that's already been performed, the claim denial risk is significant.

The one meaningful exception: young adults with primitive neuroectodermal tumors, medulloblastoma, or Ewing sarcoma family of tumors. Aetna redirects those cases to CPB 0496, which covers HCT for selected childhood solid tumors when specific criteria are met. If your patient falls into that group, stop billing under CPB 0811 and review CPB 0496 criteria directly.

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Aetna HCT for Solid Tumors Exclusions and Non-Covered Indications

This is the core of CPB 0811 — a list of 24 adult solid tumor types where Aetna considers HCT experimental, investigational, or unproven. "Effectiveness has not been established" is the stated rationale. That language matters for appeals: Aetna isn't saying the treatment is harmful, it's saying the clinical evidence doesn't yet support medical necessity at a coverage level.

The full list of non-covered indications:

Breast cancer deserves a call-out. It's on this list, but Aetna maintains a separate policy — CPB 0507 — specifically for HCT in breast cancer. Cross-reference CPB 0507 before assuming CPB 0811 is the only policy that applies to your breast cancer cases. Same goes for ovarian cancer (CPB 0635) and testicular cancer (CPB 0617).

The soft tissue sarcoma exclusion applies to autologous HCT. The CNS tumor exclusion carries the same footnote. Both carve out the young adult exception noted above — Ewing sarcoma, medulloblastoma, and PNET cases go to CPB 0496.

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Coverage Indications at a Glance

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Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

These are the steps your billing team needs to take now, given the December 4, 2025 effective date.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0811

CPT Codes — Not Covered for Indications Listed in CPB 0811

CPT Codes — Related to CPB 0811 (Coverage Status Separate)

Code	Description Copy
86813	HLA typing; A, B, or C, multiple antigens
86817	HLA typing; DR/DQ, multiple antigens
86821	HLA typing; lymphocyte culture, mixed (MLC)

HCPCS Codes — Not Covered for Indications Listed in CPB 0811

Code	Description Copy
S2142	Cord blood-derived stem cell transplantation; allogeneic
S2150	Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvest, transplantation, and related complications

Key ICD-10-CM Diagnosis Codes

These are the diagnosis codes Aetna maps to CPB 0811. Any claim pairing HCT CPT codes with these diagnoses will be evaluated — and denied — under this coverage policy.

The full ICD-10-CM code set under CPB 0811 includes 172 codes across all 24 tumor categories. Pull the complete list from the CPB 0811 source document before finalizing your charge capture edits.

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The real issue with CPB 0811 isn't the policy itself — Aetna's position on HCT for solid tumors has been consistent. The issue is the scope. With 24 tumor types, 17 non-covered CPT codes, two HCPCS codes, and 172 ICD-10-CM codes in play, the exposure for a transplant program billing these combinations is substantial. One missed flag on CPT 38241 paired with C25.9 (pancreatic cancer, unspecified) can generate a denial that takes months to resolve — and under an "experimental" designation, appeals rarely succeed without new clinical evidence. If your program bills any of these combinations with regularity, loop in your compliance officer and medical director before the December 4 effective date to set your internal review process.

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