HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-226-008
Topic:
Placental/Umbilical Cord Blood as a Source of Stem Cells
Section:
Surgery
Effective Date:
December 4, 2017
Issued Date:
January 28, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

 

Placental/umbilical cord blood, otherwise known as cord blood, is blood that remains in the placenta and in the attached umbilical cord after childbirth. Cord blood contains stem cells, which can be used to treat hematopoietic and genetic disorders through transplantation of those stem cells.

 

Policy Position

A cord blood allogeneic or otherwise known as hemopoietic stem cell transplant from related or unrelated donors may be considered medically necessary in patients with a condition or disorder for which the planned transplant is considered medically necessary and the patient has met the *transplant clinical criteria.

*Refer to referenced policies below for specific clinical criteria for allogeneic or hemopoietic stem cell transplantation.

Transplantation of cord blood stem cells from related or unrelated donors is considered experimental/investigational in all other situations including but not limited to autologous stem cell transplantation and therefore, not covered. Available scientific evidence does not permit conclusions concerning the effect of the intervention on other health outcomes.

Collection and storage of cord blood may be considered medically necessary when an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the need for allogeneic transplant.

Prophylactic collection and storage of cord blood is considered not medically necessary when proposed for some unspecified future use.

S2140

S2142

S2150

 

 

 

 

 




Related Policies

Refer to medical policy S-206 Hematopoietic Stem Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma for additional information.

Refer to medical policy S-207 Hematopoietic Stem Transplantation for Multiple Myeloma and POEMS Syndrome for additional information.

Refer to medical policy S-208 Hematopoietic Stem Transplantation for Non-Hodgkin Lymphomas for additional information.

Refer to medical policy S-210 Allogeneic Hematopoietic Stem Transplantation for Genetic Diseases and Acquired Anemia for additional information.

Refer to medical policy S-211 Hematopoietic Stem Transplantation for Epithelial Ovarian Cancer for additional information.

Refer to medical policy S-213 Hematopoietic Stem Transplantation for Autoimmune Diseases for additional information.

Refer to medical policy S-214 Hematopoietic Stem Transplantation for Acute Myeloid Leukemia for additional information.

Refer to medical policy S-215 Hematopoietic Stem Transplantation for Breast Cancer for additional information.

Refer to medical policy S-216 Hematopoietic Stem Transplantation for CNS Embryonal Tumors and Ependymoma for additional information.

Refer to medical policy S-217 Hematopoietic Stem Transplantation for Hodgkin Lymphoma for additional information.

Refer to medical policy S-218 Hematopoietic Stem Transplantation for Chronic Myeloid Leukemia for additional information.

Refer to medical policy S-220 Allogeneic and Autologous Hematopoietic Stem Transplantation for Acute Lymphoblastic Leukemia in Adults and Children for additional information.

Refer to medical policy S-222 Hematopoietic Stem Transplantation in the Treatment of Germ-Cell Tumors for additional information.

Refer to medical policy S-223 Hematopoietic Stem Transplantation for Primary Amyloidosis for additional information.

Refer to medical policy S-224 Hematopoietic Stem Transplantation for Waldenstrom Macroglobulinemia for additional information.


Place of Service: Inpatient/Outpatient

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

Transplantation of Placental/Umbilical Cord Blood as a Source of Stem Cells 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.

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.

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