HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-218-011
Topic:
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
Section:
Surgery
Effective Date:
February 11, 2019
Issued Date:
February 11, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

Hematopoietic Cell Transplantation
Hematopoietic cell transplantation (HCT) refers to a procedure in which hematopoietic 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.

Conventional Preparative Conditioning for HCT
The conventional (classical) practice of allogeneic HCT involves administration of cytotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to destroy endogenous hematopoietic capability in the recipient. The beneficial treatment effect in this procedure is due to a combination of initial eradication of malignant cells and subsequent graft-versus-malignancy (GVM) effect that develops after engraftment of allogeneic cells within the patient’s bone marrow space.

Reduced-Intensity Conditioning for Allogeneic HCT
Reduced-intensity conditioning (RIC) refers to the pretransplant use of lower doses or less intense regimens of cytotoxic drugs or radiation than are used in conventional full-dose myeloablative conditioning treatments.

Policy Position

Allogeneic HCT using a myeloablative conditioning regimen may be considered medically necessary as a treatment of chronic myeloid leukemia (CML).

Allogeneic HCT using a RIC regimen may be considered medically necessary as a treatment of chronic myeloid leukemia in individuals who meet clinical criteria for an allogeneic HCT but who are not considered candidates for a myeloablative conditioning allogeneic HCT. These include those individuals whose age (typically greater than 60 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy, low Karnofsky Performance Status) preclude use of a standard myeloablative conditioning regimen.

38204

38205

38208

38209

38210

38211

38212

38213

38214

38215

38220

38221

38222

38230

38240

S2140

S2142

 

 

 

 




Autologous cell transplantation is considered experimental/investigational and, therefore, non-covered as a treatment of CML.

Although it remains a research interest, improved outcomes have not been demonstrated for autologous HCT compared with conventional chemotherapy in individuals with CML. At this time the role of autologous HCT for this indication has not been established.

38241




Autologous blood-derived hematopoietic progenitor cell harvesting and autologous bone marrow harvesting are considered experimental/investigational and, therefore, non-covered for autologous transplantation as a treatment of CML because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

38206

38232

 

 

 

 

 




Related Policies

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

Refer to medical policy S-143 Donor Leukocyte Infusion for Hematologic Malignancies that Relapse after Allogeneic Cell Transplant for additional information.


Covered Diagnosis Codes for Procedure Codes 38204, 38205, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38222, 38230, 38240, S2140 and S2142 

C92.10

C92.12

C92.20

C92.22

 

 

 

Non-covered Diagnosis Codes for Procedure codes 38206, 38232, and 38241

C92.10

C92.12

C92.20

C92.22

 

 

 



Place of Service: Inpatient/Outpatient

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



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.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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