HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-207-012
Topic:
Hematopoietic Stem-Cell Transplantation for Multiple Myeloma and POEMS Syndrome
Section:
Surgery
Effective Date:
January 28, 2019
Issued Date:
January 28, 2019
Last Revision Date:
October 2018
Annual Review:
October 2018
 
 

Hematopoietic stem-cell transplantation (HSCT) refers to a procedure in which hematopoietic stem cells are infused to restore bone marrow function in cancer patients who receive bone-marrow-toxic doses of cytotoxic drugs with or without whole-body radiation therapy. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HSCT) or from a donor (allogeneic HSCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates.

Policy Position

A single or second (salvage) autologous HSCT may be considered medically necessary to treat multiple myeloma.

 

38206

38230

38232

38241

S2150

 

 

 

 

 

 

 

 

 




Tandem autologous HSCT may be considered medically necessary to treat multiple myeloma in patients who fail to achieve at least a near-complete or very good partial response after the first transplant in the tandem sequence. A near complete response, as defined by the European Group for Blood and Marrow Transplant (EBMT), is the disappearance of M protein at routine electrophoresis, but positive immunofixation. A very good partial response has been defined as a 90% decrease in the serum paraprotein level. 

Tandem transplantation with an initial round of autologous HSCT followed by a non-marrow-ablative conditioning regimen and allogeneic HSCT (i.e., reduced-intensity conditioning transplant) may be considered medically necessary to treat newly diagnosed multiple myeloma patients.

Autologous HSCT for the treatment of multiple myeloma that does not meet the above criteria is considered not medically necessary.

38205

38206

38240

38241

S2140

S2142

S2150

 

 

 

 

 

 

 




Allogeneic hematopoietic stem-cell transplantation, myeloablative or nonmyeloablative, as upfront therapy of newly diagnosed multiple myeloma or as salvage therapy, is considered experimental/investigational and therefore non-covered as the safety and efficacy of this service cannot be established by the available published peer review literature.

38205

38240

S2140

S2142

S2150

 

 




Autologous HSCT may be considered medically necessary to treat disseminated Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, and Skin abnormalities (POEMS) syndrome. 

38206

38241

 

 

 

 

 




Allogeneic and tandem HSCT is considered experimental/investigational to treat POEMS syndrome syndrome and therefore non-covered because the safety and/or efficacy of this service cannot be established by the available published peer review literature.

38205

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38240

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S2140

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S2150

 

 

 

 

 

 

 




Related Policies

Refer to medical policy Z-46 Blood and Bone Marrow Storage for additional information.


Covered Diagnosis Codes

Applies to autologous hematopoietic stem-cell transplants

C90.00

C90.02

 

 

 

 

 

 

  Applies to POEMS Syndrome

D47.Z9

 

 

 

 

 

 

 

Non-Covered Diagnosis Codes

Applies to allogeneic hematopoietic stem-cell transplants

C90.00

 

 

 

 

 

 

Applies to POEMS Syndrome

E88.09

 

 

 

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

HSCT for multiple myeloma and POEMS Syndrome is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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