HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-224-012
Topic:
Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia
Section:
Surgery
Effective Date:
February 11, 2019
Issued Date:
February 11, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

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 radiotherapy. Hematopoietic cells may be obtained from the transplant recipient (autologous HCT) or from a donor (allogeneic HCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates. Although cord blood is an allogeneic source, the cells in it are antigenically “naive” and are associated with a lower incidence of rejection or graft-versus-host disease (GVHD).

Policy Position

Autologous HCT may be considered medically necessary as salvage therapy of chemosensitive Waldenström macroglobulinemia.

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Allogeneic HCT is considered experimental/investigational, and therefore, non-covered to treat Waldenström macroglobulinemia. Available scientific evidence does not permit conclusions concerning this intervention on health outcomes.

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Related Policies

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


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Place of Service: Inpatient/Outpatient

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

HCT for Waldenstrom macroglobulinemia 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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