204 Form

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Medical Policy Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 204 BCBSA Reference Number: 8.01.23 (For Plan internal use only) NCD/LCD: NA Related Policies
• Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors, #247 • Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults, #191 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Autologous and allogeneic hematopoietic cell transplantation are considered INVESTIGATIONAL to treat advanced stage epithelial ovarian cancer.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for situations where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

According to the policy statement above, the following CPT and HCPCS codes are considered investigational for the conditions listed for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT codes CPT codes: Code Description 38240 Bone marrow or blood-derived peripheral stem-cell transplantation; allogeneic 38241 Bone marrow or blood-derived peripheral stem-cell transplantation; autologous HCPCS Codes HCPCS codes: Code Description S2142 Cord blood derived stem-cell transplantation, allogeneic S2150 Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)

Description Epithelial Ovarian Cancer Several types of malignancies can arise in the ovary; epithelial carcinoma is the most common. Epithelial ovarian cancer is the fifth most common cause of cancer death in women. New cases and deaths from ovarian cancer in the United States for 2024 were estimated at 19,680 and 12,740 , respectively.1, Most ovarian cancer patients present with widespread disease, and the National Cancer Institute Surveillance, Epidemiology and Results Program reported a 50.9% 5-year survival for all cases between 2014 and 2020.2,

Treatment Current management for advanced epithelial ovarian cancer is cytoreductive surgery with chemotherapy. Approximately 75% of patients present with International Federation of Gynecology and Obstetrics stage III to IV ovarian cancer and are treated with paclitaxel plus a platinum analogue (e.g. cisplatin), the preferred regimen for the newly diagnosed advanced disease.3,4, Use of platinum and taxanes has improved progression-free survival and overall survival in advanced disease to between 16 and 21 months and 32 and 57 months, respectively.3, However, cancer recurs in most women, and they die of the disease because chemotherapy drug resistance leads to uncontrolled cancer growth.4,

Hematopoietic Cell Transplantation HCT is a procedure in which hematopoietic stem cells are infused to restore bone marrow function in cancer patients who receive bone-marrow-toxic doses of drugs with or without whole body radiotherapy. Bone marrow stem cells may be obtained from the transplant recipient (autologous HCT) or a donor (allogeneic HCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates. Although cord blood is an allogeneic source, the stem cells in it are antigenically “naive” and thus are associated with a lower incidence of rejection or graft-versus-host disease.
HCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults is largely experimental. Summary

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The use of hematopoietic cell transplantation (HCT) has been investigated to treat individuals with epithelial ovarian cancer. Hematopoietic stem cells are infused to restore bone marrow function after cytotoxic doses of chemotherapeutic agents with or without whole body radiotherapy. Stem cell transplantation to treat germ cell tumors of the ovary is considered separately in medical policy #247. For individuals who have advanced-stage epithelial ovarian cancer who receive HCT, the evidence includes randomized trials and data from case series and registries. Relevant outcomes are overall survival, disease-specific survival, change in disease status, and treatment-related mortality and morbidity. Although some observational studies have reported longer survival in subsets of women with advanced epithelial ovarian cancer than in women treated with standard chemotherapy, none of the randomized trial evidence has shown a benefit from HCT in this population. Overall, the evidence has not shown that HCT improves health outcomes in treating epithelial ovarian cancer, including survival, compared with conventional standard doses of chemotherapy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 2/2026 Annual policy review. References updated. Policy statement unchanged. 10/2025 Clarified coding information 3/2025 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2023 Annual policy review. References updated. Policy statements unchanged. 2/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2021 Clarified coding information 3/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Clarified coding information 10/2020 Clarified coding information 3/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2019 Outpatient prior authorization is required for all commercial products including Medicare Advantage. Effective 1/1/2019. 6/2018 Annual policy review.
Policy statement revised to add “advanced stage” associated with epithelial ovarian cancer; intent of the policy is unchanged. Clarified coding information. Effective 6/1/2018. 3/2017 Annual policy review. New references added. Title changed. 3/1/2017 3/2016 Annual policy review. New references added. 12/2014 Annual policy review. New references added. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 2/2014 Annual policy review. New references added. 12/2012 Updated to add new CPT code 38243. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
9/2011 Reviewed - Medical Policy Group – Urology, Obstetrics and Gynecology. No changes to policy statements. 7/2011 Reviewed - Medical Policy Group – Hematology and Oncology. No changes to policy statements.

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10/2010
Reviewed - Medical Policy Group – Obstetrics and Gynecology. No changes to policy statements. 9/2010 Reviewed - Medical Policy Group – Hematology and Oncology. No changes to policy statements. 8/1/2010 Medical Policy 204 effective 8/1/2010.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. American Cancer Society. Cancer Facts & Figures 2024. Atlanta, GA: American Cancer Society; 2025; https://www.cancer.org/cancer/types/ovarian-cancer.html. Accessed November 21, 2025.
2. National Cancer Institute, Surveillance Epidemiology and End Results Program. Cancer Stat Facts: Ovarian Cancer. n.d.; https://seer.cancer.gov/statfacts/html/ovary.html. Accessed November 21,
4. Möbus V, Wandt H, Frickhofen N, et al. Phase III trial of high-dose sequential chemotherapy with peripheral blood stem cell support compared with standard dose chemotherapy for first-line treatment of advanced ovarian cancer: intergroup trial of the AGO-Ovar/AIO and EBMT. J Clin Oncol. Sep 20 2007; 25(27): 4187-93. PMID 17698804
5. Papadimitriou C, Dafni U, Anagnostopoulos A, et al. High-dose melphalan and autologous stem cell transplantation as consolidation treatment in patients with chemosensitive ovarian cancer: results of a single-institution randomized trial. Bone Marrow Transplant. Mar 2008; 41(6): 547-54. PMID 18026149
6. Donato ML, Aleman A, Champlin RE, et al. Analysis of 96 patients with advanced ovarian carcinoma treated with high-dose chemotherapy and autologous stem cell transplantation. Bone Marrow Transplant. Jun 2004; 33(12): 1219-24. PMID 15122311
7. Ledermann JA, Herd R, Maraninchi D, et al. High-dose chemotherapy for ovarian carcinoma: long- term results from the Solid Tumour Registry of the European Group for Blood and Marrow Transplantation (EBMT). Ann Oncol. May 2001; 12(5): 693-9. PMID 11432630
8. Stiff PJ, Bayer R, Kerger C, et al. High-dose chemotherapy with autologous transplantation for persistent/relapsed ovarian cancer: a multivariate analysis of survival for 100 consecutively treated patients. J Clin Oncol. Apr 1997; 15(4): 1309-17. PMID 9193322
9. Stiff PJ, Veum-Stone J, Lazarus HM, et al. High-dose chemotherapy and autologous stem-cell transplantation for ovarian cancer: an autologous blood and marrow transplant registry report. Ann Intern Med. Oct 03 2000; 133(7): 504-15. PMID 11015163
10. Sabatier R, Gonçalves A, Bertucci F, et al. Are there candidates for high-dose chemotherapy in ovarian carcinoma?. J Exp Clin Cancer Res. Oct 16 2012; 31(1): 87. PMID 23072336
11. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. Version 3.2025. https://www.nccn.org/professionals/physician_gls/PDF/ovarian.pdf. Accessed November 20, 2025.
12. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Hematopoietic Cell Transplantation (HCT). Version 3.2025. https://www.nccn.org/professionals/physician_gls/pdf/hct.pdf. Accessed November 21, 2025.
13. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Stem Cell Transplantation (110.23, formerly 110.8.1). 2024: https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?NCDId=366. Accessed November 21, 2025.