Hematology Prior Authorization and Denial Guide
Hematopoietic stem cell transplantation prior authorization criteria, bone marrow biopsy and aspiration coding rules, CAR-T therapy coverage, clotting factor infusion prior authorization, and denial patterns for hematology services. Grounded in Cigna MCP 0533 (Hematopoietic Stem Cell Transplantation), UHC HSCT Clinical Guidelines, CMS NCD 110.23, and NCCN clinical guidelines for hematologic malignancies.
Hematopoietic stem cell transplantation: allogeneic and autologous HSCT require prior authorization from all payers and typically require case management coordination. Aetna, UHC, and Cigna each publish HSCT clinical guidelines specifying the malignancies for which transplant is covered (indications include AML, ALL, CML, NHL, HL, MM, MDS, and others) and the phase of disease or disease status at which transplant is appropriate. Requests for HSCT for unlisted indications or for patients outside the standard criteria require peer-to-peer review and submission of supporting literature. Donor search and related workup (CPT 38205–38215) require authorization concurrent with HSCT authorization.
CAR-T therapy: axicabtagene ciloleucel (Yescarta), tisagenlecleucel (Kymriah), lisocabtagene maraleucel (Breyanzi), and idecabtagene vicleucel (Abecma) require prior authorization and are covered only when administered at an authorized treatment center (REMS-certified facility). Documentation requirements include pathology confirming the qualifying diagnosis, prior therapy documentation (lines of prior treatment specified by indication), performance status assessment, and organ function parameters. The manufacturing authorization and patient-specific infusion authorization are separate steps in the PA process.