{"ok":true,"total_policies":30,"policies":[{"policy_id":"CPB-1000","payer_name":"Aetna","product_or_procedure":"Cord Blood Transplantation","effective_date":"2029-07-03","last_review_date":"2027-03-03","next_review_date":"2028-03-03","coverage_criteria":["Diagnosis of an FDA-indicated hematologic malignancy or bone marrow failure disorder, as documented by treating hematologist or oncologist","Member is a suitable candidate for myeloablative or reduced-intensity conditioning regimen as determined by the requesting transplant center","No HLA-matched related donor (10/10) is available, or available donors are not medically suitable","Total nucleated cell dose for cord blood unit(s) meets minimum threshold of 2.5 x 10^7 cells/kg recipient body weight","Performance status of ECOG ≤ 2 or Karnofsky Performance Status ≥ 70%","Transplant performed at an FACT-accredited center with active cord blood transplantation program","For Aetna Open Access PPO members, network-tier specialty pharmacy must be used for cell processing logistics where applicable"],"exclusions":["Active uncontrolled infection at the time of conditioning","Concurrent malignancy with prognosis less than two years independent of transplant procedure","Member age greater than 75 years (case-by-case review required for 65-75 with reduced-intensity conditioning)","Experimental cord blood expansion or manipulation products not specifically approved by FDA under indication being requested"],"prior_authorization_required":true,"appeal_window_days":120,"cpt_codes":["38240","38241","38242","38205","38215"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00","C81.00","D46.4"],"source_url":"https://www.aetna.com/cpb/cpb-1000.html"},{"policy_id":"CPB-1015","payer_name":"Aetna","product_or_procedure":"NAM-Expanded Cord Blood Cell Therapy (Cordavex)","effective_date":"2027-12-01","last_review_date":"2026-08-31","next_review_date":"2027-08-31","coverage_criteria":["FDA-approved indication: hematologic malignancy requiring allogeneic cord blood transplantation OR refractory severe aplastic anemia with prior failure of immunosuppressive therapy","No suitable HLA-matched related or unrelated donor identified after documented search of national registries","Member is at least 12 years of age with body weight ≥ 25 kg","Bone marrow biopsy within 60 days documenting refractory disease","Treating physician has completed REMS training for nicotinamide-expanded cord blood products","Transplant scheduled at a FACT-accredited center with active cell-therapy program","For Aetna Open Access PPO members, network-tier specialty pharmacy must be used for cell processing logistics where applicable"],"exclusions":["Use in autologous transplantation","Active grade III or IV graft-versus-host disease from prior transplant","Hepatic impairment with bilirubin > 2.5x ULN (case-by-case review)","Pregnancy or nursing (per REMS)"],"prior_authorization_required":true,"appeal_window_days":180,"cpt_codes":["38240","38241","0537T","0538T"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00"],"source_url":"https://www.aetna.com/cpb/cpb-1015.html"},{"policy_id":"CPB-1034","payer_name":"Aetna","product_or_procedure":"Allogeneic Hematopoietic Stem Cell Transplantation","effective_date":"2029-04-03","last_review_date":"2027-03-03","next_review_date":"2028-03-03","coverage_criteria":["Diagnosis confirmed by bone marrow biopsy and consistent with FDA-approved indication or NCCN-endorsed off-label use","Pre-transplant evaluation performed at an FACT-accredited or JACIE-accredited center","Performance status of ECOG ≤ 2 or Karnofsky ≥ 70%","Adequate organ function as defined by center-specific institutional criteria, with documented LVEF ≥ 45%, FEV1 ≥ 50% predicted, creatinine clearance ≥ 50 mL/min","No active uncontrolled bacterial, fungal, or viral infection at time of conditioning","Confirmed donor identification and unit selection completed prior to authorization","For Aetna Open Access PPO members, network-tier specialty pharmacy must be used for cell processing logistics where applicable"],"exclusions":["Concurrent malignancy expected to limit survival to less than 2 years","HIV positivity with active opportunistic infection (HIV positive alone is no longer an exclusion)","Pregnancy"],"prior_authorization_required":true,"appeal_window_days":30,"cpt_codes":["38240","38205","38215","S2150"],"icd10_codes":["C91.00","C92.00","C92.40","C81.00","C82.00","D46.4","D61.01"],"source_url":"https://www.aetna.com/cpb/cpb-1034.html"},{"policy_id":"CPB-1045","payer_name":"Aetna","product_or_procedure":"CAR-T Cell Therapy","effective_date":"2022-12-03","last_review_date":"2026-03-03","next_review_date":"2027-03-03","coverage_criteria":["FDA-approved indication for the specific CAR-T product being requested","Documented failure or intolerance of all FDA-approved alternative therapies for the indication","Adequate cardiac, pulmonary, hepatic, and renal function as defined by product labeling","Performance status of ECOG ≤ 2","No active CNS disease or active second malignancy","Treatment to be administered at a REMS-certified treatment center","For Aetna Open Access PPO members, network-tier specialty pharmacy must be used for cell processing logistics where applicable"],"exclusions":["Prior CAR-T therapy targeting the same antigen (case-by-case review for retreatment)","Active graft-versus-host disease","Pregnancy or breastfeeding"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38240","0537T","0538T","Q2041","Q2042"],"icd10_codes":["C91.00","C83.30","C83.39","C84.40"],"source_url":"https://www.aetna.com/cpb/cpb-1045.html"},{"policy_id":"CPB-1076","payer_name":"Aetna","product_or_procedure":"Gene Therapy for Sickle Cell Disease","effective_date":"2024-01-01","last_review_date":"2025-05-01","next_review_date":"2026-05-01","coverage_criteria":["Confirmed diagnosis of sickle cell disease (HbSS, HbSβ0-thalassemia)","History of severe vaso-occlusive crises (≥4 per year for ≥2 years) or chronic transfusion dependence","Member age 12-50 years (some products approved 12+)","Failed or contraindicated to hydroxyurea","No HLA-matched sibling donor available for allogeneic transplant","Treatment at REMS-certified center with documented experience in autologous gene therapy","For Aetna Open Access PPO members, network-tier specialty pharmacy must be used for cell processing logistics where applicable"],"exclusions":["Active malignancy or history of malignancy within 5 years","Cardiac, hepatic, pulmonary, or renal impairment beyond product-specific thresholds","Pregnancy or unable to use contraception","Prior HSCT"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38205","38240","0489T"],"icd10_codes":["D57.00","D57.01","D57.20","D57.40"],"source_url":"https://www.aetna.com/cpb/cpb-1076.html"},{"policy_id":"MCP-1116","payer_name":"UnitedHealthcare","product_or_procedure":"Cord Blood Transplantation","effective_date":"2027-07-01","last_review_date":"2027-05-01","next_review_date":"2028-05-01","coverage_criteria":["Diagnosis of an FDA-indicated hematologic malignancy or bone marrow failure disorder, as documented by treating hematologist or oncologist","Member is a suitable candidate for myeloablative or reduced-intensity conditioning regimen as determined by the requesting transplant center","No HLA-matched related donor (10/10) is available, or available donors are not medically suitable","Total nucleated cell dose for cord blood unit(s) meets minimum threshold of 2.5 x 10^7 cells/kg recipient body weight","Performance status of ECOG ≤ 2 or Karnofsky Performance Status ≥ 70%","Transplant performed at an FACT-accredited center with active cord blood transplantation program","United Healthcare Optum case management referral required prior to scheduling; case manager will coordinate benefit verification"],"exclusions":["Active uncontrolled infection at the time of conditioning","Concurrent malignancy with prognosis less than two years independent of transplant procedure","Member age greater than 75 years (case-by-case review required for 65-75 with reduced-intensity conditioning)","Experimental cord blood expansion or manipulation products not specifically approved by FDA under indication being requested"],"prior_authorization_required":true,"appeal_window_days":120,"cpt_codes":["38240","38241","38242","38205","38215"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00","C81.00","D46.4"],"source_url":"https://www.uhcprovider.com/policies/mcp-1116.html"},{"policy_id":"MCP-1140","payer_name":"UnitedHealthcare","product_or_procedure":"NAM-Expanded Cord Blood Cell Therapy (Cordavex)","effective_date":"2022-10-03","last_review_date":"2026-03-03","next_review_date":"2027-03-03","coverage_criteria":["FDA-approved indication: hematologic malignancy requiring allogeneic cord blood transplantation OR refractory severe aplastic anemia with prior failure of immunosuppressive therapy","No suitable HLA-matched related or unrelated donor identified after documented search of national registries","Member is at least 12 years of age with body weight ≥ 25 kg","Bone marrow biopsy within 60 days documenting refractory disease","Treating physician has completed REMS training for nicotinamide-expanded cord blood products","Transplant scheduled at a FACT-accredited center with active cell-therapy program","United Healthcare Optum case management referral required prior to scheduling; case manager will coordinate benefit verification"],"exclusions":["Use in autologous transplantation","Active grade III or IV graft-versus-host disease from prior transplant","Hepatic impairment with bilirubin > 2.5x ULN (case-by-case review)","Pregnancy or nursing (per REMS)"],"prior_authorization_required":true,"appeal_window_days":120,"cpt_codes":["38240","38241","0537T","0538T"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00"],"source_url":"https://www.uhcprovider.com/policies/mcp-1140.html"},{"policy_id":"MCP-1153","payer_name":"UnitedHealthcare","product_or_procedure":"Allogeneic Hematopoietic Stem Cell Transplantation","effective_date":"2023-07-31","last_review_date":"2025-03-31","next_review_date":"2026-03-31","coverage_criteria":["Diagnosis confirmed by bone marrow biopsy and consistent with FDA-approved indication or NCCN-endorsed off-label use","Pre-transplant evaluation performed at an FACT-accredited or JACIE-accredited center","Performance status of ECOG ≤ 2 or Karnofsky ≥ 70%","Adequate organ function as defined by center-specific institutional criteria, with documented LVEF ≥ 45%, FEV1 ≥ 50% predicted, creatinine clearance ≥ 50 mL/min","No active uncontrolled bacterial, fungal, or viral infection at time of conditioning","Confirmed donor identification and unit selection completed prior to authorization","United Healthcare Optum case management referral required prior to scheduling; case manager will coordinate benefit verification"],"exclusions":["Concurrent malignancy expected to limit survival to less than 2 years","HIV positivity with active opportunistic infection (HIV positive alone is no longer an exclusion)","Pregnancy"],"prior_authorization_required":true,"appeal_window_days":30,"cpt_codes":["38240","38205","38215","S2150"],"icd10_codes":["C91.00","C92.00","C92.40","C81.00","C82.00","D46.4","D61.01"],"source_url":"https://www.uhcprovider.com/policies/mcp-1153.html"},{"policy_id":"MCP-1176","payer_name":"UnitedHealthcare","product_or_procedure":"CAR-T Cell Therapy","effective_date":"2028-01-01","last_review_date":"2027-10-01","next_review_date":"2028-10-01","coverage_criteria":["FDA-approved indication for the specific CAR-T product being requested","Documented failure or intolerance of all FDA-approved alternative therapies for the indication","Adequate cardiac, pulmonary, hepatic, and renal function as defined by product labeling","Performance status of ECOG ≤ 2","No active CNS disease or active second malignancy","Treatment to be administered at a REMS-certified treatment center","United Healthcare Optum case management referral required prior to scheduling; case manager will coordinate benefit verification"],"exclusions":["Prior CAR-T therapy targeting the same antigen (case-by-case review for retreatment)","Active graft-versus-host disease","Pregnancy or breastfeeding"],"prior_authorization_required":true,"appeal_window_days":60,"cpt_codes":["38240","0537T","0538T","Q2041","Q2042"],"icd10_codes":["C91.00","C83.30","C83.39","C84.40"],"source_url":"https://www.uhcprovider.com/policies/mcp-1176.html"},{"policy_id":"MCP-1203","payer_name":"UnitedHealthcare","product_or_procedure":"Gene Therapy for Sickle Cell Disease","effective_date":"2022-10-01","last_review_date":"2024-12-31","next_review_date":"2025-12-31","coverage_criteria":["Confirmed diagnosis of sickle cell disease (HbSS, HbSβ0-thalassemia)","History of severe vaso-occlusive crises (≥4 per year for ≥2 years) or chronic transfusion dependence","Member age 12-50 years (some products approved 12+)","Failed or contraindicated to hydroxyurea","No HLA-matched sibling donor available for allogeneic transplant","Treatment at REMS-certified center with documented experience in autologous gene therapy","United Healthcare Optum case management referral required prior to scheduling; case manager will coordinate benefit verification"],"exclusions":["Active malignancy or history of malignancy within 5 years","Cardiac, hepatic, pulmonary, or renal impairment beyond product-specific thresholds","Pregnancy or unable to use contraception","Prior HSCT"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38205","38240","0489T"],"icd10_codes":["D57.00","D57.01","D57.20","D57.40"],"source_url":"https://www.uhcprovider.com/policies/mcp-1203.html"},{"policy_id":"PHC-1210","payer_name":"Cigna","product_or_procedure":"Cord Blood Transplantation","effective_date":"2022-12-01","last_review_date":"2025-01-31","next_review_date":"2026-01-31","coverage_criteria":["Diagnosis of an FDA-indicated hematologic malignancy or bone marrow failure disorder, as documented by treating hematologist or oncologist","Member is a suitable candidate for myeloablative or reduced-intensity conditioning regimen as determined by the requesting transplant center","No HLA-matched related donor (10/10) is available, or available donors are not medically suitable","Total nucleated cell dose for cord blood unit(s) meets minimum threshold of 2.5 x 10^7 cells/kg recipient body weight","Performance status of ECOG ≤ 2 or Karnofsky Performance Status ≥ 70%","Transplant performed at an FACT-accredited center with active cord blood transplantation program","Cigna Centers of Excellence designation must be in place for the requesting transplant center, or single-case agreement obtained from Cigna medical director"],"exclusions":["Active uncontrolled infection at the time of conditioning","Concurrent malignancy with prognosis less than two years independent of transplant procedure","Member age greater than 75 years (case-by-case review required for 65-75 with reduced-intensity conditioning)","Experimental cord blood expansion or manipulation products not specifically approved by FDA under indication being requested"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38240","38241","38242","38205","38215"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00","C81.00","D46.4"],"source_url":"https://static.cigna.com/coverage-policies/phc-1210.html"},{"policy_id":"PHC-1232","payer_name":"Cigna","product_or_procedure":"NAM-Expanded Cord Blood Cell Therapy (Cordavex)","effective_date":"2022-07-01","last_review_date":"2025-05-01","next_review_date":"2026-05-01","coverage_criteria":["FDA-approved indication: hematologic malignancy requiring allogeneic cord blood transplantation OR refractory severe aplastic anemia with prior failure of immunosuppressive therapy","No suitable HLA-matched related or unrelated donor identified after documented search of national registries","Member is at least 12 years of age with body weight ≥ 25 kg","Bone marrow biopsy within 60 days documenting refractory disease","Treating physician has completed REMS training for nicotinamide-expanded cord blood products","Transplant scheduled at a FACT-accredited center with active cell-therapy program","Cigna Centers of Excellence designation must be in place for the requesting transplant center, or single-case agreement obtained from Cigna medical director"],"exclusions":["Use in autologous transplantation","Active grade III or IV graft-versus-host disease from prior transplant","Hepatic impairment with bilirubin > 2.5x ULN (case-by-case review)","Pregnancy or nursing (per REMS)"],"prior_authorization_required":true,"appeal_window_days":60,"cpt_codes":["38240","38241","0537T","0538T"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00"],"source_url":"https://static.cigna.com/coverage-policies/phc-1232.html"},{"policy_id":"PHC-1270","payer_name":"Cigna","product_or_procedure":"Allogeneic Hematopoietic Stem Cell Transplantation","effective_date":"2025-01-31","last_review_date":"2025-08-31","next_review_date":"2026-08-31","coverage_criteria":["Diagnosis confirmed by bone marrow biopsy and consistent with FDA-approved indication or NCCN-endorsed off-label use","Pre-transplant evaluation performed at an FACT-accredited or JACIE-accredited center","Performance status of ECOG ≤ 2 or Karnofsky ≥ 70%","Adequate organ function as defined by center-specific institutional criteria, with documented LVEF ≥ 45%, FEV1 ≥ 50% predicted, creatinine clearance ≥ 50 mL/min","No active uncontrolled bacterial, fungal, or viral infection at time of conditioning","Confirmed donor identification and unit selection completed prior to authorization","Cigna Centers of Excellence designation must be in place for the requesting transplant center, or single-case agreement obtained from Cigna medical director"],"exclusions":["Concurrent malignancy expected to limit survival to less than 2 years","HIV positivity with active opportunistic infection (HIV positive alone is no longer an exclusion)","Pregnancy"],"prior_authorization_required":true,"appeal_window_days":60,"cpt_codes":["38240","38205","38215","S2150"],"icd10_codes":["C91.00","C92.00","C92.40","C81.00","C82.00","D46.4","D61.01"],"source_url":"https://static.cigna.com/coverage-policies/phc-1270.html"},{"policy_id":"PHC-1295","payer_name":"Cigna","product_or_procedure":"CAR-T Cell Therapy","effective_date":"2027-02-01","last_review_date":"2026-12-01","next_review_date":"2027-12-01","coverage_criteria":["FDA-approved indication for the specific CAR-T product being requested","Documented failure or intolerance of all FDA-approved alternative therapies for the indication","Adequate cardiac, pulmonary, hepatic, and renal function as defined by product labeling","Performance status of ECOG ≤ 2","No active CNS disease or active second malignancy","Treatment to be administered at a REMS-certified treatment center","Cigna Centers of Excellence designation must be in place for the requesting transplant center, or single-case agreement obtained from Cigna medical director"],"exclusions":["Prior CAR-T therapy targeting the same antigen (case-by-case review for retreatment)","Active graft-versus-host disease","Pregnancy or breastfeeding"],"prior_authorization_required":true,"appeal_window_days":30,"cpt_codes":["38240","0537T","0538T","Q2041","Q2042"],"icd10_codes":["C91.00","C83.30","C83.39","C84.40"],"source_url":"https://static.cigna.com/coverage-policies/phc-1295.html"},{"policy_id":"PHC-1334","payer_name":"Cigna","product_or_procedure":"Gene Therapy for Sickle Cell Disease","effective_date":"2022-03-31","last_review_date":"2025-05-31","next_review_date":"2026-05-31","coverage_criteria":["Confirmed diagnosis of sickle cell disease (HbSS, HbSβ0-thalassemia)","History of severe vaso-occlusive crises (≥4 per year for ≥2 years) or chronic transfusion dependence","Member age 12-50 years (some products approved 12+)","Failed or contraindicated to hydroxyurea","No HLA-matched sibling donor available for allogeneic transplant","Treatment at REMS-certified center with documented experience in autologous gene therapy","Cigna Centers of Excellence designation must be in place for the requesting transplant center, or single-case agreement obtained from Cigna medical director"],"exclusions":["Active malignancy or history of malignancy within 5 years","Cardiac, hepatic, pulmonary, or renal impairment beyond product-specific thresholds","Pregnancy or unable to use contraception","Prior HSCT"],"prior_authorization_required":true,"appeal_window_days":30,"cpt_codes":["38205","38240","0489T"],"icd10_codes":["D57.00","D57.01","D57.20","D57.40"],"source_url":"https://static.cigna.com/coverage-policies/phc-1334.html"},{"policy_id":"SURG-1357","payer_name":"Anthem","product_or_procedure":"Cord Blood Transplantation","effective_date":"2023-03-31","last_review_date":"2025-08-31","next_review_date":"2026-08-31","coverage_criteria":["Diagnosis of an FDA-indicated hematologic malignancy or bone marrow failure disorder, as documented by treating hematologist or oncologist","Member is a suitable candidate for myeloablative or reduced-intensity conditioning regimen as determined by the requesting transplant center","No HLA-matched related donor (10/10) is available, or available donors are not medically suitable","Total nucleated cell dose for cord blood unit(s) meets minimum threshold of 2.5 x 10^7 cells/kg recipient body weight","Performance status of ECOG ≤ 2 or Karnofsky Performance Status ≥ 70%","Transplant performed at an FACT-accredited center with active cord blood transplantation program","Anthem AIM Specialty Health prior authorization portal must be used for submission; faxed requests will be returned"],"exclusions":["Active uncontrolled infection at the time of conditioning","Concurrent malignancy with prognosis less than two years independent of transplant procedure","Member age greater than 75 years (case-by-case review required for 65-75 with reduced-intensity conditioning)","Experimental cord blood expansion or manipulation products not specifically approved by FDA under indication being requested"],"prior_authorization_required":true,"appeal_window_days":180,"cpt_codes":["38240","38241","38242","38205","38215"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00","C81.00","D46.4"],"source_url":"https://www.anthem.com/policies/surg-1357.html"},{"policy_id":"SURG-1376","payer_name":"Anthem","product_or_procedure":"NAM-Expanded Cord Blood Cell Therapy (Cordavex)","effective_date":"2022-11-01","last_review_date":"2025-12-01","next_review_date":"2026-12-01","coverage_criteria":["FDA-approved indication: hematologic malignancy requiring allogeneic cord blood transplantation OR refractory severe aplastic anemia with prior failure of immunosuppressive therapy","No suitable HLA-matched related or unrelated donor identified after documented search of national registries","Member is at least 12 years of age with body weight ≥ 25 kg","Bone marrow biopsy within 60 days documenting refractory disease","Treating physician has completed REMS training for nicotinamide-expanded cord blood products","Transplant scheduled at a FACT-accredited center with active cell-therapy program","Anthem AIM Specialty Health prior authorization portal must be used for submission; faxed requests will be returned"],"exclusions":["Use in autologous transplantation","Active grade III or IV graft-versus-host disease from prior transplant","Hepatic impairment with bilirubin > 2.5x ULN (case-by-case review)","Pregnancy or nursing (per REMS)"],"prior_authorization_required":true,"appeal_window_days":180,"cpt_codes":["38240","38241","0537T","0538T"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00"],"source_url":"https://www.anthem.com/policies/surg-1376.html"},{"policy_id":"SURG-1386","payer_name":"Anthem","product_or_procedure":"Allogeneic Hematopoietic Stem Cell Transplantation","effective_date":"2027-09-01","last_review_date":"2027-10-01","next_review_date":"2028-10-01","coverage_criteria":["Diagnosis confirmed by bone marrow biopsy and consistent with FDA-approved indication or NCCN-endorsed off-label use","Pre-transplant evaluation performed at an FACT-accredited or JACIE-accredited center","Performance status of ECOG ≤ 2 or Karnofsky ≥ 70%","Adequate organ function as defined by center-specific institutional criteria, with documented LVEF ≥ 45%, FEV1 ≥ 50% predicted, creatinine clearance ≥ 50 mL/min","No active uncontrolled bacterial, fungal, or viral infection at time of conditioning","Confirmed donor identification and unit selection completed prior to authorization","Anthem AIM Specialty Health prior authorization portal must be used for submission; faxed requests will be returned"],"exclusions":["Concurrent malignancy expected to limit survival to less than 2 years","HIV positivity with active opportunistic infection (HIV positive alone is no longer an exclusion)","Pregnancy"],"prior_authorization_required":true,"appeal_window_days":180,"cpt_codes":["38240","38205","38215","S2150"],"icd10_codes":["C91.00","C92.00","C92.40","C81.00","C82.00","D46.4","D61.01"],"source_url":"https://www.anthem.com/policies/surg-1386.html"},{"policy_id":"SURG-1394","payer_name":"Anthem","product_or_procedure":"CAR-T Cell Therapy","effective_date":"2024-10-31","last_review_date":"2026-01-31","next_review_date":"2027-01-31","coverage_criteria":["FDA-approved indication for the specific CAR-T product being requested","Documented failure or intolerance of all FDA-approved alternative therapies for the indication","Adequate cardiac, pulmonary, hepatic, and renal function as defined by product labeling","Performance status of ECOG ≤ 2","No active CNS disease or active second malignancy","Treatment to be administered at a REMS-certified treatment center","Anthem AIM Specialty Health prior authorization portal must be used for submission; faxed requests will be returned"],"exclusions":["Prior CAR-T therapy targeting the same antigen (case-by-case review for retreatment)","Active graft-versus-host disease","Pregnancy or breastfeeding"],"prior_authorization_required":true,"appeal_window_days":60,"cpt_codes":["38240","0537T","0538T","Q2041","Q2042"],"icd10_codes":["C91.00","C83.30","C83.39","C84.40"],"source_url":"https://www.anthem.com/policies/surg-1394.html"},{"policy_id":"SURG-1418","payer_name":"Anthem","product_or_procedure":"Gene Therapy for Sickle Cell Disease","effective_date":"2024-05-31","last_review_date":"2025-12-31","next_review_date":"2026-12-31","coverage_criteria":["Confirmed diagnosis of sickle cell disease (HbSS, HbSβ0-thalassemia)","History of severe vaso-occlusive crises (≥4 per year for ≥2 years) or chronic transfusion dependence","Member age 12-50 years (some products approved 12+)","Failed or contraindicated to hydroxyurea","No HLA-matched sibling donor available for allogeneic transplant","Treatment at REMS-certified center with documented experience in autologous gene therapy","Anthem AIM Specialty Health prior authorization portal must be used for submission; faxed requests will be returned"],"exclusions":["Active malignancy or history of malignancy within 5 years","Cardiac, hepatic, pulmonary, or renal impairment beyond product-specific thresholds","Pregnancy or unable to use contraception","Prior HSCT"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38205","38240","0489T"],"icd10_codes":["D57.00","D57.01","D57.20","D57.40"],"source_url":"https://www.anthem.com/policies/surg-1418.html"},{"policy_id":"MCG-1444","payer_name":"Humana","product_or_procedure":"Cord Blood Transplantation","effective_date":"2024-10-03","last_review_date":"2026-03-03","next_review_date":"2027-03-03","coverage_criteria":["Diagnosis of an FDA-indicated hematologic malignancy or bone marrow failure disorder, as documented by treating hematologist or oncologist","Member is a suitable candidate for myeloablative or reduced-intensity conditioning regimen as determined by the requesting transplant center","No HLA-matched related donor (10/10) is available, or available donors are not medically suitable","Total nucleated cell dose for cord blood unit(s) meets minimum threshold of 2.5 x 10^7 cells/kg recipient body weight","Performance status of ECOG ≤ 2 or Karnofsky Performance Status ≥ 70%","Transplant performed at an FACT-accredited center with active cord blood transplantation program","Humana case management may require peer-to-peer discussion prior to approval for first-time requests"],"exclusions":["Active uncontrolled infection at the time of conditioning","Concurrent malignancy with prognosis less than two years independent of transplant procedure","Member age greater than 75 years (case-by-case review required for 65-75 with reduced-intensity conditioning)","Experimental cord blood expansion or manipulation products not specifically approved by FDA under indication being requested"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38240","38241","38242","38205","38215"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00","C81.00","D46.4"],"source_url":"https://www.humana.com/medical-coverage-policies/mcg-1444.html"},{"policy_id":"MCG-1477","payer_name":"Humana","product_or_procedure":"NAM-Expanded Cord Blood Cell Therapy (Cordavex)","effective_date":"2027-03-31","last_review_date":"2026-05-31","next_review_date":"2027-05-31","coverage_criteria":["FDA-approved indication: hematologic malignancy requiring allogeneic cord blood transplantation OR refractory severe aplastic anemia with prior failure of immunosuppressive therapy","No suitable HLA-matched related or unrelated donor identified after documented search of national registries","Member is at least 12 years of age with body weight ≥ 25 kg","Bone marrow biopsy within 60 days documenting refractory disease","Treating physician has completed REMS training for nicotinamide-expanded cord blood products","Transplant scheduled at a FACT-accredited center with active cell-therapy program","Humana case management may require peer-to-peer discussion prior to approval for first-time requests"],"exclusions":["Use in autologous transplantation","Active grade III or IV graft-versus-host disease from prior transplant","Hepatic impairment with bilirubin > 2.5x ULN (case-by-case review)","Pregnancy or nursing (per REMS)"],"prior_authorization_required":true,"appeal_window_days":90,"cpt_codes":["38240","38241","0537T","0538T"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00"],"source_url":"https://www.humana.com/medical-coverage-policies/mcg-1477.html"},{"policy_id":"MCG-1518","payer_name":"Humana","product_or_procedure":"Allogeneic Hematopoietic Stem Cell Transplantation","effective_date":"2022-10-31","last_review_date":"2025-10-31","next_review_date":"2026-10-31","coverage_criteria":["Diagnosis confirmed by bone marrow biopsy and consistent with FDA-approved indication or NCCN-endorsed off-label use","Pre-transplant evaluation performed at an FACT-accredited or JACIE-accredited center","Performance status of ECOG ≤ 2 or Karnofsky ≥ 70%","Adequate organ function as defined by center-specific institutional criteria, with documented LVEF ≥ 45%, FEV1 ≥ 50% predicted, creatinine clearance ≥ 50 mL/min","No active uncontrolled bacterial, fungal, or viral infection at time of conditioning","Confirmed donor identification and unit selection completed prior to authorization","Humana case management may require peer-to-peer discussion prior to approval for first-time requests"],"exclusions":["Concurrent malignancy expected to limit survival to less than 2 years","HIV positivity with active opportunistic infection (HIV positive alone is no longer an exclusion)","Pregnancy"],"prior_authorization_required":true,"appeal_window_days":30,"cpt_codes":["38240","38205","38215","S2150"],"icd10_codes":["C91.00","C92.00","C92.40","C81.00","C82.00","D46.4","D61.01"],"source_url":"https://www.humana.com/medical-coverage-policies/mcg-1518.html"},{"policy_id":"MCG-1530","payer_name":"Humana","product_or_procedure":"CAR-T Cell Therapy","effective_date":"2027-01-01","last_review_date":"2026-07-01","next_review_date":"2027-07-01","coverage_criteria":["FDA-approved indication for the specific CAR-T product being requested","Documented failure or intolerance of all FDA-approved alternative therapies for the indication","Adequate cardiac, pulmonary, hepatic, and renal function as defined by product labeling","Performance status of ECOG ≤ 2","No active CNS disease or active second malignancy","Treatment to be administered at a REMS-certified treatment center","Humana case management may require peer-to-peer discussion prior to approval for first-time requests"],"exclusions":["Prior CAR-T therapy targeting the same antigen (case-by-case review for retreatment)","Active graft-versus-host disease","Pregnancy or breastfeeding"],"prior_authorization_required":true,"appeal_window_days":180,"cpt_codes":["38240","0537T","0538T","Q2041","Q2042"],"icd10_codes":["C91.00","C83.30","C83.39","C84.40"],"source_url":"https://www.humana.com/medical-coverage-policies/mcg-1530.html"},{"policy_id":"MCG-1561","payer_name":"Humana","product_or_procedure":"Gene Therapy for Sickle Cell Disease","effective_date":"2025-03-31","last_review_date":"2026-01-31","next_review_date":"2027-01-31","coverage_criteria":["Confirmed diagnosis of sickle cell disease (HbSS, HbSβ0-thalassemia)","History of severe vaso-occlusive crises (≥4 per year for ≥2 years) or chronic transfusion dependence","Member age 12-50 years (some products approved 12+)","Failed or contraindicated to hydroxyurea","No HLA-matched sibling donor available for allogeneic transplant","Treatment at REMS-certified center with documented experience in autologous gene therapy","Humana case management may require peer-to-peer discussion prior to approval for first-time requests"],"exclusions":["Active malignancy or history of malignancy within 5 years","Cardiac, hepatic, pulmonary, or renal impairment beyond product-specific thresholds","Pregnancy or unable to use contraception","Prior HSCT"],"prior_authorization_required":true,"appeal_window_days":60,"cpt_codes":["38205","38240","0489T"],"icd10_codes":["D57.00","D57.01","D57.20","D57.40"],"source_url":"https://www.humana.com/medical-coverage-policies/mcg-1561.html"},{"policy_id":"FEP-1581","payer_name":"BCBS Federal","product_or_procedure":"Cord Blood Transplantation","effective_date":"2023-06-01","last_review_date":"2026-05-01","next_review_date":"2027-05-01","coverage_criteria":["Diagnosis of an FDA-indicated hematologic malignancy or bone marrow failure disorder, as documented by treating hematologist or oncologist","Member is a suitable candidate for myeloablative or reduced-intensity conditioning regimen as determined by the requesting transplant center","No HLA-matched related donor (10/10) is available, or available donors are not medically suitable","Total nucleated cell dose for cord blood unit(s) meets minimum threshold of 2.5 x 10^7 cells/kg recipient body weight","Performance status of ECOG ≤ 2 or Karnofsky Performance Status ≥ 70%","Transplant performed at an FACT-accredited center with active cord blood transplantation program","FEP Blue Focus members may require additional documentation per the FEP Medical Policy Manual"],"exclusions":["Active uncontrolled infection at the time of conditioning","Concurrent malignancy with prognosis less than two years independent of transplant procedure","Member age greater than 75 years (case-by-case review required for 65-75 with reduced-intensity conditioning)","Experimental cord blood expansion or manipulation products not specifically approved by FDA under indication being requested"],"prior_authorization_required":true,"appeal_window_days":60,"cpt_codes":["38240","38241","38242","38205","38215"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00","C81.00","D46.4"],"source_url":"https://www.fepblue.org/policies/fep-1581.html"},{"policy_id":"FEP-1593","payer_name":"BCBS Federal","product_or_procedure":"NAM-Expanded Cord Blood Cell Therapy (Cordavex)","effective_date":"2023-04-01","last_review_date":"2026-05-01","next_review_date":"2027-05-01","coverage_criteria":["FDA-approved indication: hematologic malignancy requiring allogeneic cord blood transplantation OR refractory severe aplastic anemia with prior failure of immunosuppressive therapy","No suitable HLA-matched related or unrelated donor identified after documented search of national registries","Member is at least 12 years of age with body weight ≥ 25 kg","Bone marrow biopsy within 60 days documenting refractory disease","Treating physician has completed REMS training for nicotinamide-expanded cord blood products","Transplant scheduled at a FACT-accredited center with active cell-therapy program","FEP Blue Focus members may require additional documentation per the FEP Medical Policy Manual"],"exclusions":["Use in autologous transplantation","Active grade III or IV graft-versus-host disease from prior transplant","Hepatic impairment with bilirubin > 2.5x ULN (case-by-case review)","Pregnancy or nursing (per REMS)"],"prior_authorization_required":true,"appeal_window_days":120,"cpt_codes":["38240","38241","0537T","0538T"],"icd10_codes":["D61.01","D61.09","D61.1","C92.00","C92.40","C91.00"],"source_url":"https://www.fepblue.org/policies/fep-1593.html"},{"policy_id":"FEP-1629","payer_name":"BCBS Federal","product_or_procedure":"Allogeneic Hematopoietic Stem Cell Transplantation","effective_date":"2026-12-01","last_review_date":"2026-07-31","next_review_date":"2027-07-31","coverage_criteria":["Diagnosis confirmed by bone marrow biopsy and consistent with FDA-approved indication or NCCN-endorsed off-label use","Pre-transplant evaluation performed at an FACT-accredited or JACIE-accredited center","Performance status of ECOG ≤ 2 or Karnofsky ≥ 70%","Adequate organ function as defined by center-specific institutional criteria, with documented LVEF ≥ 45%, FEV1 ≥ 50% predicted, creatinine clearance ≥ 50 mL/min","No active uncontrolled bacterial, fungal, or viral infection at time of conditioning","Confirmed donor identification and unit selection completed prior to authorization","FEP Blue Focus members may require additional documentation per the FEP Medical Policy Manual"],"exclusions":["Concurrent malignancy expected to limit survival to less than 2 years","HIV positivity with active opportunistic infection (HIV positive alone is no longer an exclusion)","Pregnancy"],"prior_authorization_required":true,"appeal_window_days":180,"cpt_codes":["38240","38205","38215","S2150"],"icd10_codes":["C91.00","C92.00","C92.40","C81.00","C82.00","D46.4","D61.01"],"source_url":"https://www.fepblue.org/policies/fep-1629.html"},{"policy_id":"FEP-1669","payer_name":"BCBS Federal","product_or_procedure":"CAR-T Cell Therapy","effective_date":"2024-08-31","last_review_date":"2025-08-31","next_review_date":"2026-08-31","coverage_criteria":["FDA-approved indication for the specific CAR-T product being requested","Documented failure or intolerance of all FDA-approved alternative therapies for the indication","Adequate cardiac, pulmonary, hepatic, and renal function as defined by product labeling","Performance status of ECOG ≤ 2","No active CNS disease or active second malignancy","Treatment to be administered at a REMS-certified treatment center","FEP Blue Focus members may require additional documentation per the FEP Medical Policy Manual"],"exclusions":["Prior CAR-T therapy targeting the same antigen (case-by-case review for retreatment)","Active graft-versus-host disease","Pregnancy or breastfeeding"],"prior_authorization_required":true,"appeal_window_days":120,"cpt_codes":["38240","0537T","0538T","Q2041","Q2042"],"icd10_codes":["C91.00","C83.30","C83.39","C84.40"],"source_url":"https://www.fepblue.org/policies/fep-1669.html"},{"policy_id":"FEP-1707","payer_name":"BCBS Federal","product_or_procedure":"Gene Therapy for Sickle Cell Disease","effective_date":"2029-01-31","last_review_date":"2026-12-31","next_review_date":"2027-12-31","coverage_criteria":["Confirmed diagnosis of sickle cell disease (HbSS, HbSβ0-thalassemia)","History of severe vaso-occlusive crises (≥4 per year for ≥2 years) or chronic transfusion dependence","Member age 12-50 years (some products approved 12+)","Failed or contraindicated to hydroxyurea","No HLA-matched sibling donor available for allogeneic transplant","Treatment at REMS-certified center with documented experience in autologous gene therapy","FEP Blue Focus members may require additional documentation per the FEP Medical Policy Manual"],"exclusions":["Active malignancy or history of malignancy within 5 years","Cardiac, hepatic, pulmonary, or renal impairment beyond product-specific thresholds","Pregnancy or unable to use contraception","Prior HSCT"],"prior_authorization_required":true,"appeal_window_days":30,"cpt_codes":["38205","38240","0489T"],"icd10_codes":["D57.00","D57.01","D57.20","D57.40"],"source_url":"https://www.fepblue.org/policies/fep-1707.html"}]}