38204 CPT® code: payer coverage and prior authorization59 of 60 payer prior-auth lists that name 38204 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California, Blue Shield of California Promise Health Plan, Cigna, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Shield of California | Blue Shield Medicare | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield Medicare | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Cigna | ACA/IFP | All | prior auth required | Oct 1, 2006 | Master Precertification List (For Health Care Providers) | |
| Cigna | Basic Standard | All | prior auth required | Oct 1, 2006 | Master Precertification List (For Health Care Providers) | |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | Oct 1, 2006 | Master Precertification List (For Health Care Providers) | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Jan 1, 2026 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 | |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 | |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth required | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
38204 appears in 90 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Capital Blue Cross, Centene, Cigna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (0780) | listed, no stance (range 38204-38205) | Apr 27, 2026 | payer document |
| Aetna | Alpha1-Proteinase Inhibitors (0145) | not covered | Mar 24, 2026 | payer document |
| Aetna | Atidarsagene Autotemcel (Lenmeldy) (1058) | listed, no stance | Jul 13, 2026 | payer document |
| Aetna | Bendamustine Products (0875) | listed, no stance (range 38204-38215) | Sep 15, 2026 | payer document |
| Aetna | Brentuximab Vedotin (Adcetris) (0823) | listed, no stance | Sep 24, 2026 | payer document |
| Aetna | Donor Lymphocyte Infusion (0638) | covered if criteria are met (range 38204-38205) | Sep 29, 2026 | payer document |
| Aetna | Erythropoiesis Stimulating Agents (0195) | not covered (range 38204-38232) | Jan 20, 2026 | payer document |
| Aetna | Extracorporeal Photochemotherapy (Photopheresis) (0241) | listed, no stance (range 38204-38230) | Apr 13, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Aplastic Anemia and other Bone Marrow Failure Syndromes (0627) | listed, no stance (range 38204-38215) | Sep 23, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (0606) | not covered | Sep 18, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia (0674) | listed, no stance (range 38204-38215) | Oct 7, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Hodgkin's Disease (0495) | covered if criteria are met | Jul 2, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Inherited Metabolic Disorders and Genetic Diseases (0871) | covered if criteria are met | Dec 22, 2025 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Multiple Myeloma (0497) | listed, no stance | Aug 5, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Myelodysplastic Syndrome (0836) | listed, no stance | Dec 9, 2025 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Myelofibrosis (0838) | covered if criteria are met (range 38204-38205) | Dec 9, 2025 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma (0494) | listed, no stance (range 38204-38215) | Aug 3, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496) | listed, no stance (range 38204-38215) | Aug 6, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Solid Tumors in Adults (0811) | not covered | Dec 3, 2025 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia (0626) | covered if criteria are met | Sep 18, 2026 | payer document |
| Aetna | Hypoxic Ischemic Encephalopathy (0812) | not covered (range 38204-38205) | Nov 20, 2025 | payer document |
| Aetna | Marnetegragene Autotemcel (Kresladi) (1102) | listed, no stance | Jul 13, 2026 | payer document |
| Aetna | Motixafortide (Aphexda) (1046) | listed, no stance | Dec 11, 2025 | payer document |
| Aetna | Multiple Sclerosis (0264) | not covered | Sep 10, 2026 | payer document |
| Aetna | Narsoplimab-wuug (Yartemlea) (1099) | listed, no stance | Apr 27, 2026 | payer document |
| Aetna | Non-myeloablative Hematopoietic Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant) (0634) | covered if criteria are met (range 38204-38205) | Sep 25, 2026 | payer document |
| Aetna | Omidubicel-onlv (Omisirge) (1032) | listed, no stance | Apr 27, 2026 | payer document |
| Aetna | Pegzilarginase-nbln (Loargys) (1101) | listed, no stance | Jun 26, 2026 | payer document |
| Aetna | Stem Cells for Hematopoietic Cell Transplant (0190) | covered if criteria are met | Mar 27, 2026 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors (TRANS.00031) | unproven / investigational | May 14, 2026 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Diabetes Mellitus (TRANS.00034) | unproven / investigational | Nov 6, 2025 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias (TRANS.00029) | covered if criteria are met | Nov 6, 2025 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Germ Cell Tumors (TRANS.00030) | unproven / investigational | Nov 6, 2025 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma (TRANS.00028) | covered if criteria are met | May 14, 2026 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias (TRANS.00023) | covered if criteria are met | Nov 6, 2025 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors (TRANS.00027) | covered if criteria are met | Nov 6, 2025 | payer document |
| Anthem | Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome (TRANS.00024) | covered if criteria are met | Nov 6, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Allogeneic Hematopoietic Cell Transplantation For Genetic Diseases And Acquired Anemias (L.8.01.412) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Allogeneic Hematopoietic Cell Transplantation For Myelodysplastic Syndromes And Myeloproliferative Neoplasms | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Autologous Hematopoietic Stemcell Transplantation For Malignant Astrocytomas And Gliomas (L.8.01.405) | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Acute Lymphoblastic Leukemia | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Acute Myeloid Leukemia | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Chronic Lymphocytic Leukemiasmall Lymphocytic Lymphoma | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Chronic Myeloid Leukemia | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Cns Embryonal Tumors And Ependymoma | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Epithelial Ovarian Cancer | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Hodgkin Lymphoma | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Miscellaneous Solid Tumors In Adults | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Nonhodgkin Lymphomas | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Plasma Cell Dyscrasias Including Multiple Myeloma And Poems Syndrome | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Primary Amyloidosis Or Waldenstroms Macroglobulinemia | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation For Solid Tumors Of Childhood | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Cell Transplantation In The Treatment Of Germ Cell Tumors | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hematopoietic Stemcell Transplantation For Breast Cancer (L.8.01.410) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Nonmyeloablative Allogeneic Transplants Of Hematopoietic Stemcells For Treatment Of Malignancy (L.8.01.406) | covered if criteria are met | payer document | |
| BlueCross BlueShield of South Carolina | Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (CAM 80121) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas (CAM 80131) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia (CAM 80132) | listed, no stance | Jun 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Breast Cancer (CAM 80127) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma (CAM 80128) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CAM 80115) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia (CAM 80130) | listed, no stance | Feb 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer (CAM 80123) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Hodgkin Lymphoma (CAM 80129) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (CAM 80124) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Primary Amyloidosis (CAM 80142) | listed, no stance | Apr 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation for Solid Tumors of Childhood (CAM 80134) | listed, no stance | May 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors (CAM 80135) | listed, no stance | Apr 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia (CAM 80126) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Stem Cell Transplantation for Autoimmune Diseases (CAM 80125) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas (CAM 80120) | listed, no stance | Jul 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome (CAM 80117) | listed, no stance | Jan 1, 2026 | payer document |
| Capital Blue Cross | Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (MP 9.056) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia (MP 9.041) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Acute Myeloid Leukemia (MP 9.040) Procedure codes | covered if criteria are met | May 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Autoimmune diseases (MP 9.053) Procedure codes | unproven / investigational | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma (MP 9.050) Procedure codes | covered if criteria are met | May 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma (MP 9.038) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia (MP 9.039) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer (MP 9.047) Procedure codes | unproven / investigational | May 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Hodgkin Lymphoma (MP 9.043) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (MP 9.048) Procedure codes | unproven / investigational | May 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas (MP 9.042) Procedure Codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and Poems Syndrome (MP 9.044) Procedure Codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Primary Amyloidosis (MP 9.045) Procedure codes | covered if criteria are met | May 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation for Solid Tumors of Childhood (MP 9.054) Procedure Codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors (MP 9.052) Procedure Codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Centene | Nonmyeloablative Allogeneic Stem Cell Transplants Reference Number: CP.MP.141 (CP.MP.141) | covered if criteria are met | Jan 1, 2026 | payer document |
| Cigna | Hematology - Omisirge (IP0817) | covered if criteria are met | Aug 1, 2026 | payer document |
| Cigna | Stem Cell Transplantation: Blood Cancers (0533) | covered if criteria are met | Aug 15, 2026 | payer document |
Prior authorization required or conditional in IN.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.