Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

This policy covers hematopoietic cell transplantation (autologous and allogeneic HCT) for pediatric and adult acute lymphoblastic leukemia (ALL), including high‑risk first complete remission, second or greater remission, relapsed or refractory disease, and relapsing pediatric ALL after prior autologous HCT. Coverage is subject to the member’s benefit plan and detailed Policy Guidelines (specific high‑risk criteria such as t(9;22), high presenting WBC, hypodiploidy, T‑cell/ProB immunophenotypes, or poor induction response), requires adequate organ function and HLA‑matched donors for allogeneic HCT, and autologous HCT for adult second+/refractory ALL is generally considered investigational and not covered.

"Hematopoietic cell transplantation (HCT) for childhood (pediatric) acute lymphoblastic leukemia."

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