Non-myeloablative Hematopoietic Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant)

Non‑myeloablative hematopoietic cell transplantation is covered as medically necessary only for patients with indications where conventional allogeneic HCT is an established alternative (acute lymphoblastic leukemia, acute myelogenous leukemia, aplastic anemia including PNH, and chronic lymphocytic leukemia) and is considered experimental/investigational for other conditions (e.g., autoimmune diseases, most solid tumors such as breast, melanoma, ovarian, renal, testicular, essential thrombocythemia/polycythemia vera, inherited hemophagocytic lymphohistiocytosis, and other immune/autoimmune disorders listed). Coverage is conditional on meeting the policy’s selection criteria (CPT/HCPCS codes payable only if criteria are met), and mini‑allograft is investigational for patients who are ineligible for conventional allogeneic SCT; the policy also notes significant risks (GVHD, infections) and limited long‑term evidence for many uses.

"Acute myelogenous leukemia (AML)"