Hematopoietic Cell Transplantation (HCT) involves the intravenous (IV) infusion of allogeneic (donor) or autologous stem cells to reestablish hematopoietic function in individuals whose bone marrow or immune system is damaged or defective. They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates.
A variety of blood cancers may be treated with either allogeneic or autologous HCT, including but not limited to:
Donor lymphocyte infusion (DLI), also called donor leukocyte or buffy-coat infusion, is another type of therapy in which T lymphocytes from the blood of a donor are given to a patient who has already received a hematopoietic cell transplant (HCT) from the same donor. The DLI therapeutic effect results from a graft-versus-leukemic or graft-versus-tumor effect due to recognition of certain antigens on the cancer cells by the donor lymphocytes and the resultant elimination of the tumor cells.
Acute Lymphoblastic Leukemia (ALL)
Adult ALL
Allogeneic HCT may be considered medically necessary to treat adult ALL when at least ONE of the following clinical criteria has been met:
A second allogeneic HCT to treat ALL when relapsed disease occurs more than six (6) months after initial allogeneic HCT may be considered medically necessary.
Note:
High-risk* for relapse may include but are not limited to:
Allogeneic HCT to treat adult ALL not meeting the criteria as listed in this policy considered not medically necessary.
Autologous HCT to treat adult ALL in first complete remission but at high-risk* of relapse may be considered medically necessary.
Autologous HCT to treat adult ALL not meeting the criteria as indicated in this policy is considered not medically necessary.
Pediatric ALL
Autologous or allogeneic HCT may be considered medically necessary to treat pediatric ALL when at least ONE of the following clinical criteria has been met:
Allogeneic HCT may be considered medically necessary to treat relapsing ALL after a prior autologous HCT in pediatric individuals.
Autologous or allogeneic HCT not meeting the criteria as indicated in this policy is considered not medically necessary.
Reduced-Intensity Conditioning (RIC) for ALL
RIC allogeneic HCT may be considered medically necessary as a treatment for ALL in individuals who are in complete marrow and extramedullary first or second remission, and who, for medical reasons, would be unable to tolerate a standard myeloablative conditioning regimen.
RIC HCT not meeting the criteria as listed in this policy is considered not medically necessary.
Guidelines for Autologous and Allogeneic HCT in ALL
Indication |
Children (Age <18 Years) |
Adults (Age ≥18 Years) |
||
|
Allogeneic HCT |
Autologous HCT |
Allogeneic HCT |
Autologous HCT |
First complete response, standard-risk |
N |
N |
S |
N |
First complete response, high-risk |
S |
N |
S |
N |
Second complete response |
S |
N |
S |
N |
At least third complete response |
C |
N |
S |
N |
Not in remission |
C |
N |
S |
N |
ALL: acute lymphoblastic leukemia; C: clinical evidence available; HCT: hematopoietic cell transplantation; N: not generally recommended; S: standard of care.
Acute Myeloid Leukemia (AML)
Allogeneic HCT using a myeloablative conditioning regimen may be considered medically necessary to treat ANY of the following conditions:
Allogeneic HCT using a reduced-intensity conditioning regimen may be considered medically necessary as a treatment of AML in individuals who are in complete marrow and extramedullary remission (CR1 and beyond), and who for medical reasons would be unable to tolerate a myeloablative conditioning regimen.
Autologous HCT may be considered medically necessary in individuals who are not candidates for allogenic HCT to treat AML in CR1 or beyond, or relapsed AML, if responsive to intensified induction chemotherapy.
The use of allogeneic or autologous HCT in individuals to treat AML not meeting the criteria as indicated in this policy is considered not medically necessary.
Risk status of AML based on Genetic Factors
The newer, currently preferred, World Health Organization classification of AML incorporates and interrelates morphology, cytogenetics, molecular genetics, and immunologic markers. It attempts to construct a classification that is universally applicable and prognostically valid. The World Health Organization system was adapted by National Comprehensive Cancer Network to estimate individual patient prognosis to guide management, as shown in the below table.
Risk Status |
Genetic Abnormalities |
Favorable |
t(8;21)(q22;q22.1); RUNX1-RUNX1T1 |
Intermediate |
Mutated NPM1 and FLT3-ITDhigh |
Poor/Adverse |
t(6;9)(p23;q34.1); DEK-NUP214 |
AML: Acute myeloid leukemia; ITD: Internal tandem duplication
Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
Allogeneic HCT may be considered medically necessary to treat individuals with markers of poor-risk disease for EITHER of the following conditions:
Use of a myeloablative or reduced-intensity pre-transplant conditioning regimen should be individualized based on factors that include individual age, the presence of comorbidities, and disease burden.
Allogeneic HCT to treat CLL or SLL not meeting the criteria as indicated in this policy is considered not medically necessary.
Chronic Myeloid Leukemia (CML)
Allogeneic HCT to treat CML may be considered medically necessary for ANY of the following indications:
Allogeneic HCT using a reduced-intensity conditioning (RIC) regimen to treat CML may be considered medically necessary for the following:
Allogeneic HCT to treat CML not meeting the criteria as indicated in this policy is considered not medically necessary.
Hodgkin Lymphoma (HL)
The following HCT treatments may be considered medically necessary for individuals with primary refractory or relapsed HL:
Tandem autologous HCT may be considered medically necessary:
Autologous or allogeneic HCT to treat Hodgkin lymphoma not meeting the criteria as listed in this policy is considered not medically necessary.
Lugano Classification Staging System for Hodgkin Lymphoma
The staging system used for Hodgkin lymphoma is the Lugano classification. It has 4 stages, labeled I, II, III, and IV. For limited stage (I or II) HL that affects an organ outside of the lymph system, the letter E is added to the stage (for example, stage IE or IIE).
Stage |
Area of Concern |
I |
|
II |
|
III |
|
IV |
|
Note: The number of lymph node regions involved may be indicated by a subscript (e.g., II3).
Each stage may also be assigned a letter (A or B). B is added (stage IIIB, for example) if a person has ANY of these B symptoms:
If a person has any B symptoms, it usually means the lymphoma is more advanced, and more intensive treatment is often recommended. If no B symptoms are present, the letter A is added to the stage.
PET 5-Point Scale (Deauville Criteria) for Hodgkin Lymphoma
Score |
PET/CT Scan Result |
|
Negative |
1 |
No uptake |
2 |
Uptake less than or equal to mediastinum |
|
3 |
Uptake greater than mediastinum but less than or equal to liver |
|
Positive |
4 |
Uptake moderately higher than liver and visually above adjacent background activity |
5 |
Uptake markedly higher than liver and/or new lesions |
|
Xa |
New areas of uptake unlikely to be related to lymphoma |
|
a Watchful waiting, biopsy, or additional imaging tests may be appropriate depending on clinical circumstances. Obtaining a second opinion/overread of the imaging may be beneficial.
Multiple Myeloma (MM)
A single or second (salvage) autologous HCT may be considered medically necessary to treat MM.
Tandem autologous HCT may be considered medically necessary to treat MM in individuals who fail to achieve at least a near-complete or very good partial response after the first transplant in the tandem sequence.
Tandem transplantation with an initial round of autologous HCT followed by a non-marrow-ablative conditioning regimen and allogeneic HCT (i.e., reduced-intensity conditioning (RIC) transplant) may be considered medically necessary to treat newly diagnosed MM individuals.
Autologous HCT, single or tandem, or allogeneic HCT RIC used to treat MM not meeting the criteria as indicated in this policy is considered not medically necessary.
Myelodysplastic Syndromes and Myeloproliferative Neoplasms
Myeloablative allogeneic HCT may be considered medically necessary as a treatment of EITHER of the following conditions:
Reduced-intensity conditioning allogeneic HCT may be considered medically necessary as a risk-adapted treatment in individuals, who for medical reasons would be unable to tolerate a myeloablative conditioning regimen as a treatment of EITHER of the following conditions:
Myeloablative allogeneic HCT or reduced-intensity conditioning allogeneic HCT for myelodysplastic syndromes and myeloproliferative neoplasms not meeting the criteria as indicated in this policy is considered not medically necessary.
Non-Hodgkin Lymphoma (NHL)
Aggressive NHL B-cell Subtype
Allogeneic HCT using a myeloablative conditioning regimen or autologous HCT may be considered medically necessary to treat individuals with aggressive NHL B-cell subtypes (EXCEPT mantle cell lymphoma) for ANY of the following:
Allogeneic HCT to treat individuals with aggressive NHL B-cell subtypes not meeting the criteria as listed in this policy are considered not medically necessary.
Indolent NHL B-cell Subtype
Allogeneic HCT using a myeloablative conditioning regimen or autologous HCT maybe considered medically necessary to treat individuals with indolent NHL B-cell subtypes for ANY of the following:
Allogeneic HCT to treat individuals with indolent NHL B-cell subtypes not meeting the criteria as listed in this policy are considered not medically necessary.
Mantle Cell Lymphoma
Autologous HCT may be considered medically necessary to consolidate a first remission of mantle cell lymphoma.
Salvage Therapy for Mantle Cell Lymphoma
HCT to treat mantle cell lymphoma
not meeting the criteria as indicated in this policy is considered not
medically necessary.
RIC for NHL
Reduced-intensity conditioning (RIC) allogeneic HCT to treat individuals with NHL may be considered medically necessary for those individuals who meet the above criteria for an allogeneic HCT but who do not qualify for a myeloablative allogeneic HCT.
RIC allogeneic HCT not meeting the criteria to treat NHL as indicated in this policy is considered not medically necessary.
T-Cell Lymphoma
HCT may be considered medically necessary for individuals with mature T-cell or natural killer cell (peripheral T-cell) neoplasms as follows:
Autologous or allogeneic HCT for treatment of T-cell lymphoma not meeting the criteria as indicated in this policy is considered not medically necessary.
Note: Please see attached table or WHO classification
of Non-Hodgkin Lymphomas.
POEMS Syndrome
Autologous HCT to treat disseminated POEMS Syndrome may be considered medically necessary for individuals who are eligible as EITHER:
Autologous
HCT to treat disseminated POEMS Syndrome not meeting the criteria as indicated in this
policy is considered not medically necessary.
Primary Systemic Amyloidosis (AL)
Autologous HCT to treat primary systemic AL may be considered medically necessary when ALL the following patient selection criteria are met:
Note:
When available, a clinical trial should be utilized.
Autologous HCT to treat primary systemic AL not meeting the criteria as indicated in this policy is considered not medically necessary.
Waldenström Macroglobulinemia (WM)
Autologous HCT to treat previously treated WM may be considered medically necessary.
Autologous HCT not meeting the
criteria as indicated in this policy is considered not medically necessary.
Allogeneic HCT, either ablative or non-ablative, to treat previously treated WM may be considered medically necessary.
Allogeneic HCT to treat previously
treated WM not meeting the criteria as indicated in this policy is considered not
medically necessary.
Experimental/Investigational
The following conditions for autologous HCT or allogeneic HCT to treat individuals for blood cancers are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:
Allogeneic HCT Procedure Codes
38205 |
38230 |
38240 |
38242 |
S2140 |
S2142 |
S2150 |
Autologous HCT Procedure Codes
38206 |
38232 |
38241 |
S2150 |
|
|
|
Donor Leukocyte Infusion
DLI may be considered medically necessary for adults and children following allogeneic HCT that was originally considered medically necessary for the treatment of a hematologic malignancy that has relapsed, or does not respond, to prevent relapse in the setting of a high risk of relapse, or to convert a patient from mixed to full donor chimerism with ANY of the following conditions:
DLI not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this services cannot be established by the available published peer-reviewed literature.
Charges for the leukapheresis procedure for the donor are eligible for payment when the donor leukocyte infusion is covered. Payment for eligible donor leukapheresis procedures may be equated to therapeutic apheresis for white blood cells.
Experimental/Investigational
The following procedures concerning DLI are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:
36511 |
38242 |
|
|
|
|
|
Refer to Medical Policy S-11, Pheresis Therapy, for additional information.
Refer to Medical Policy S-226, Placenta/Umbilical Cord Blood as a Source of Stem Cells, for additional information.
Refer to Medical Policy V-37, Autism Spectrum Disorders, for additional information.
Refer to Medical Policy Z-46, Blood and Bone Marrow Storage, for additional information.
National Comprehensive Cancer Network – 2022
Acute Lymphoblastic Leukemia
Adult ALL – v.1.2022
Current National Comprehensive Cancer Network guidelines for ALL indicate allo-HCT is appropriate for consolidation treatment of most poor risk (eg, the Philadelphia chromosome-positive, relapsed, or refractory) patients with ALL. The guidelines
state that for appropriately fit older adults with ALL who are achieving remission, “consideration of autologous or reduced-intensity allogeneic stem cell transplantation may be appropriate.” In addition, the guidelines note that chronologic age is not a good surrogate for fitness for therapy and that patient should be evaluated on an individual basis.
Pediatric ALL – v.1.2022
Current National Comprehensive Cancer Network guidelines for pediatric ALL recommend "Allogeneic HSCT has demonstrated improved clinical outcomes in pediatric ALL patients with evidence of certain high-risk features and/or persistent disease. In addition, survival rates appear to be comparable regardless of the stem cell source (matched related, matched unrelated, cord blood, or haploidentical donor)." The guidelines state that the benefit of allo-HCT in infants is still controversial.
Acute Myeloid Leukemia – v.3.2023
NCCN guidelines recommend:
In patients younger than 60 years of age:
· Patients with antecedent hematologic disease or treatment-related AML are considered poor-risk, unless they have favorable cytogenetics. HLA testing should be performed promptly in those who may be candidates for either fully ablative or reduced-intensity conditioning (RIC) allogeneic HCT from a matched sibling or an alternative donor, which constitutes the best option for long-term disease control.
In patients 60 years or older:
· After induction, with residual disease, consider allogeneic HCT.
· Allogeneic transplant is a reasonable option in patients who experience failure after re-induction with certain regimens (eg, intermediate- or high-dose cytarabine), and have identified donors available to start conditioning within 4–6 weeks from start of induction therapy. Patients without an identified donor would most likelyneed some additional therapy as a bridge to transplant. HCT may be appropriate for patients with a low level of residual disease post-induction (eg, patients with prior MDS who reverted back to MDS with <10% blasts). It is preferred that this approach be given in the context of a clinical trial.
· Post-remission therpy, allogeneic HCT
· Post-induction therapy, allogeneic HCT
In patients greater than or equal to 18 years of age:
· Surveillance and relapse/refractory disease (algorithm)
o Matched sibling or alternate donor HCT
o If a second complete response is achieved, then consolidation with allogeneic HCT should be considered.
B-Cell Lymphomas – v.2.2023
Follicular Lymphoma Stage 1 or 2
NCCN guidelines recommend allogeneic hematopoietic cell transplant in selected cases as a second line consolidation or extended dosing.
Diffuse Large B-Cell, Marginal Zone, Burkitt, or Mantle Cell Lymphoma
NCCN guidelines recommend high dose therapy with autologous stem cell rescue or allogeneic hematopoietic cell transplant in highly select cases as a second line consolidation therapy.
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma – v.2.2023
Allogeneic HCT can be considered for CLL/SLL relapsed or refractory disease after prior therapy with BTKi- and venetoclax-based regimens in [individuals] without significant comorbidities. HCT-specific comorbidity index (HCT-Cl) could be used for the assessment of comorbidities prior to HCT and to predict the risks of non-relapse mortality and the probabilities of survival after HCT.
For individuals with CLL/SLL with del(17p) or TP53 mutation, a discussion of allogeneic HCT could be considered for [individuals] in remission with or after ibrutnib therapy, if CK (greater than or equal to 3 abnormalities) is present. However, available data suggests that CK (greater than or equal to 5 abnormalities) associated with inferior overall survival and EFS following allogeneic HCT with reduced-intensity conditioning in patients with high-risk interphase cytoge
Chronic Myeloid Leukemia – v.1.2023
Current NCCN guidelines recommend allogeneic hematopoietic cell transplantation (allo-HCT) as an alternative treatment only for high-risk settings or in patients with advanced phase chronic myeloid leukemia (CML). Relevant recommendations a
The Network guidelines also state: "Non-myeloablative allogeneic HCT is a well-tolerated treatment option for patients with a matched donor and the selection of patients is based on their age and the presence of comorbidities."
Autologous HCT for CML is not addressed in these guidelines.
Donor Leukocyte Infusion – 2022
National Comprehensive Cancer Network (NCCN) – 2022
NCCN recommendations for treating ALL (v.1.2022) patients with disease that relapses after an initial allogeneic HCT, may include a second allogeneic HCT and/or DLI.
NCCN states for pediatric ALL (v.1.2022), “one of the early treatments for [individuals] with advanced ALL included adoptive cell therapy to induce a graft-versus-leukemia effect through allogeneic HSCT or donor lymphocyte infusions. However, this method resulted in a significant graft-versus-host disease (GVHD).”
NCCN recommendations for treating CML (v.3.2022) state that DLI is effective in inducing durable molecular remissions in the majority of patients with relapsed CML following allogeneic HCT, though it is more effective in patients with chronic phase relapse than advanced phase relapse.
NCCN guidelines for AML (v.1.2022) has the following statement. “A study suggests that azacytidine followed by donor lymphocyte infusions may be a treatment option for therapy in [individuals] who have AML that relapses after allogeneic HCT. These data are based on a prospective phase II trial.”
NCCN recommendations for treating MM (v.5.2022) state that individuals whose disease does not respond to or relapses after allogeneic hematopoietic cell grafting may receive donor lymphocyte infusions to stimulate a beneficial graft-versus-myeloma effect or other myeloma therapies on or off a clinical trial.
Hodgkin Lymphoma – v.2.2023
Current National Comprehensive Cancer Network guidelines for HL, include:
Multiple Myeloma – v.3.2023
According to the NCCN guidelines, for transplant-eligible patients autologous HCT is the preferred option after primary induction therapy while a delayed HCT after early stem cell collection and storage is appropriate as well. A repeat HCT can be considered for treatment of progressive/refractory disease after primary treatment in patients with prolonged response to initial HCT.
According to the NCCN Multiple Myeloma Panel, an autologous tandem transplant with or without maintenance therapy can be considered for all patients who are candidates for HCT and is an option for patients who do not achieve at least a VPGR after the first autologous HCT and those with high-risk features.
A second autologous HCT can be considered at the time of disease relapse.
Allogeneic HCT includes either myeloablative or nonmyeloablative (ie,"mini" transplant) transplants. Allogeneic HCT has been investigated as an alternative to autologous HCT to avoid the contamination of reinfused autologous tumor cells, but also to take advantage of the beneficial graft-versus-tumor effect associated with allogeneic transplants. However, lack of a suitable donor and increased morbidity has limited this approach, particularly for the typical older MM population.
Myelodysplastic Syndromes – v.1.2023
Allogeneic HCT from an HLA-matched sibling, matched unrelated, or alternative donor is a preferred approach for treating select individuals with MDS, particularly those with high-risk disease. This includes both standard and RIC strategies.
Myeloproliferative Neoplasms – v.3.2022
Allogeneic HCT is the only potentially curative treatment option resulting in long-term remissions for patients with MF. However, the use of myeloablative conditioning is associated with higher rates of non-relapse mortality (NRM). The use of reduced-intensity conditioning (RIC) has lowered the rates of NRM, but is also associated with a higher risk of relapse compared to myeloablative conditioning.
POEMS Syndrome – Multiple Myeloma – v.3.2023
Treatment: Autologous hematopoietic cell transplantation in patients who are eligible as sole therapy or as consolidation after induction therapy. Individualize treatment based on response and toxicity of prior therapy and patient’s performance status at the time of progression.
Systemic Light Chain Amyloidosis – v.2.2023
The National Comprehensive Cancer Network guidelines on systemic light chain amyloidosis (v.1.2022) recommend assessing organ involvement based on amyloidosis consensus criteria in newly diagnosed disease. Next, patients should be evaluated for stem cell transplant candidacy. The current guidelines list the following as therapeutic considerations for management of patients (all category 2A recommendations) along with best supportive care: "high-dose melphalan followed by autologous stem cell transplantation; oral melphalan and dexamethasone; dexamethasone in combination with alpha-interferon; thalidomide plus dexamethasone; lenalidomide and dexamethasone; lenalidomide/cyclophosphamide/dexamethasone; pomalidomide and dexamethasone; bortezomib with or without dexamethasone; bortezomib with melphalan plus dexamethasone; cyclophosphamide, thalidomide, and dexamethasone; and cyclophosphamide, bortezomib, and dexamethasone." Since the optimal therapy remains unknown, the NCCN "strongly encourages treatment in the context of a clinical trial when possible."
T-Cell Lymphomas – v.1.2023
Peripheral T-Cell Lymphoma
NCCN guidelines recommends considering high dose therapy with autologous stem cell transplant for high-risk IPI patients in CR1. For relapsed/refractory disease consider allogeneic hematopoietic cell transplant (HCT) or consider high-dose therapy with autologous stem cell rescue.
Adult T-Cell Lymphoma
NCCN guidelines recommends considering allogeneic HCT as additional therapy for acute adult t-cell leukemia/lymphoma.
T-Cell Prolymphocytic Leukemia
NCCN guidelines recommend in patients who achieve a CR or PR following initial therapy, consolidation with allogeneic HCT should be considered. Autologous HCT may be considered, if a donor is not available and if the patient is not physically fit to undergo allogeneic HCT.
Waldenström Macroglobulinemia – v.1.2023
National Comprehensive Cancer Network guidelines on Waldenström macroglobulinemia (WM) and lymphoplasmacytic lymphoma (v.2.2022) indicate that, for patients with previously treated WM, stem cell transplantation may be appropriate in selected cases with either: high-dose therapy with autologous stem cell rescue or allogeneic cell transplant (myeloablative or nonmyeloablative). The Network noted that allogeneic cell transplantation “should ideally be undertaken in the context of a clinical trial.” For potential autologous cell transplantation candidates, the guidelines also provide suggested treatment regimens considered non-stem-cell toxic.
Acute Lymphoblastic Leukemia
Covered Diagnosis Codes for Procedure Codes: 38205, 38206, 38230, 38232, 38240, 38241, S2140, S2142
C91.00 |
C91.01 |
C91.02 |
|
|
|
|
Acute Myeloid Leukemia
Covered Diagnosis Codes for Procedure Codes: 38205, 38206, 38230, 38232, 38240, 38241, S2140, S2142, and S2150
C92.00 |
C92.01 |
C92.02 |
C92.40 |
C92.41 |
C92.42 |
C92.50 |
C92.51 |
C92.52 |
C92.60 |
C92.61 |
C92.62 |
C92.A0 |
C92.A1 |
C92.A2 |
C93.00 |
C93.01 |
C93.02 |
C94.00 |
C94.01 |
C94.02 |
C94.20 |
C94.21 |
C94.22 |
|
|
|
|
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
Covered Diagnosis Codes for Procedure Codes: 38205, 38240, S2140, and S2142
C91.10 |
C91.11 |
|
|
|
|
|
Chronic Myeloid Leukemia
Covered Diagnosis Codes for Procedure Codes: 38205, 38220, 38221, 38222, 38230, 38240, S2140 and S2142
C92.10 |
C92.12 |
C92.20 |
C92.22 |
|
|
|
Hodgkin Lymphoma
Covered Diagnosis Codes for Procedure Codes: 38205, 38206, 38230, 38232, 38240, 38241, S2140, S2142, and S2150
C81.00 |
C81.01 |
C81.02 |
C81.03 |
C81.04 |
C81.05 |
C81.06 |
C81.07 |
C81.08 |
C81.09 |
C81.10 |
C81.11 |
C81.12 |
C81.13 |
C81.14 |
C81.15 |
C81.16 |
C81.17 |
C81.18 |
C81.19 |
C81.20 |
C81.21 |
C81.22 |
C81.23 |
C81.24 |
C81.25 |
C81.26 |
C81.27 |
C81.28 |
C81.29 |
C81.30 |
C81.31 |
C81.32 |
C81.33 |
C81.34 |
C81.35 |
C81.36 |
C81.37 |
C81.38 |
C81.39 |
C81.40 |
C81.41 |
C81.42 |
C81.43 |
C81.44 |
C81.45 |
C81.46 |
C81.47 |
C81.48 |
C81.49 |
C81.70 |
C81.71 |
C81.72 |
C81.73 |
C81.74 |
C81.75 |
C81.76 |
C81.77 |
C81.78 |
C81.79 |
C81.90 |
C81.91 |
C81.92 |
C81.93 |
C81.94 |
C81.95 |
C81.96 |
C81.97 |
C81.98 |
C81.99 |
Multiple Myeloma
Covered Diagnosis Codes for Procedure Codes: 38206, 38232, 38241, and S2150
C90.00 |
C90.02 |
|
|
|
|
|
Myelodysplastic Syndromes and Myeloproliferative Neoplasms
Covered Diagnosis Codes for Procedure Codes: 38205, 38230, 38240, S2140, S2142, and S2150
C94.40 |
C94.41 |
C94.42 |
C94.6 |
D46.0 |
D46.1 |
D46.20 |
D46.21 |
D46.22 |
D46.4 |
D46.9 |
D46.A |
D46.B |
D46.C |
D46.Z |
D47.1 |
D47.Z9 |
|
|
|
|
Non-Hodgkin Lymphoma
Covered Diagnosis Coeds for Procedure Codes:38205, 38206, 38230, 38232, 38240, 38241, S2140, S2142, and S2150
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.50 |
C83.51 |
C83.52 |
C83.53 |
C83.54 |
C83.55 |
C83.56 |
C83.57 |
C83.58 |
C83.59 |
C83.70 |
C83.71 |
C83.72 |
C83.73 |
C83.74 |
C83.75 |
C83.76 |
C83.77 |
C83.78 |
C83.79 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C83.90 |
C83.91 |
C83.92 |
C83.93 |
C83.94 |
C83.95 |
C83.96 |
C83.97 |
C83.98 |
C83.99 |
C84.40 |
C84.41 |
C84.42 |
C84.43 |
C84.44 |
C84.45 |
C84.46 |
C84.47 |
C84.48 |
C84.49 |
C84.60 |
C84.61 |
C84.62 |
C84.63 |
C84.64 |
C84.65 |
C84.66 |
C84.67 |
C84.68 |
C84.69 |
C84.70 |
C84.71 |
C84.72 |
C84.73 |
C84.74 |
C84.75 |
C84.76 |
C84.77 |
C84.78 |
C84.79 |
C84.90 |
C84.91 |
C84.92 |
C84.93 |
C84.94 |
C84.95 |
C84.96 |
C84.97 |
C84.98 |
C84.99 |
C84.A0 |
C84.A1 |
C84.A2 |
C84.A3 |
C84.A4 |
C84.A5 |
C84.A6 |
C84.A7 |
C84.A8 |
C84.A9 |
C84.Z0 |
C84.Z1 |
C84.Z2 |
C84.Z3 |
C84.Z4 |
C84.Z5 |
C84.Z6 |
C84.Z7 |
C84.Z8 |
C84.Z9 |
C85.10 |
C85.11 |
C85.12 |
C85.13 |
C85.14 |
C85.15 |
C85.16 |
C85.17 |
C85.18 |
C85.19 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C85.90 |
C85.91 |
C85.92 |
C85.93 |
C85.94 |
C85.95 |
C85.96 |
C85.97 |
C85.98 |
C85.99 |
C88.80 |
C88.81 |
|
|
|
|
|
|
|
|
|
|
|
POEMS
Covered Diagnosis Codes for Procedure Codes: 38206, 38232, 38241, and S2150
D47.Z9 |
|
|
|
|
|
|
Primary Systemic Amyloidosis
Covered Diagnosis Codes for Procedure Codes: 38206, 38232, 38241, S2150
E85.81 |
|
|
|
|
|
|
Waldenström Macroglobulinemia
Covered Diagnosis Code for Procedure Codes:
C88.00 |
C88.01 |
|
|
|
|
|
Donor Leukocyte Infusion
Covered Diagnosis Codes for Procedure Code: 38242
C81.00 |
C81.01 |
C81.02 |
C81.03 |
C81.04 |
C81.05 |
C81.06 |
C81.07 |
C81.08 |
C81.09 |
C81.10 |
C81.11 |
C81.12 |
C81.13 |
C81.14 |
C81.15 |
C81.16 |
C81.17 |
C81.18 |
C81.19 |
C81.20 |
C81.21 |
C81.22 |
C81.23 |
C81.24 |
C81.25 |
C81.26 |
C81.27 |
C81.28 |
C81.29 |
C81.30 |
C81.31 |
C81.32 |
C81.33 |
C81.34 |
C81.35 |
C81.36 |
C81.37 |
C81.38 |
C81.39 |
C81.40 |
C81.41 |
C81.42 |
C81.43 |
C81.44 |
C81.45 |
C81.46 |
C81.47 |
C81.48 |
C81.49 |
C81.70 |
C81.71 |
C81.72 |
C81.73 |
C81.74 |
C81.75 |
C81.76 |
C81.77 |
C81.78 |
C81.79 |
C81.90 |
C81.91 |
C81.92 |
C81.93 |
C81.94 |
C81.95 |
C81.96 |
C81.97 |
C81.98 |
C81.99 |
C90.00 |
C90.01 |
C90.02 |
C91.00 |
C91.01 |
C91.02 |
C91.10 |
C91.11 |
C91.12 |
C91.30 |
C91.31 |
C91.32 |
C91.50 |
C91.51 |
C91.52 |
C91.60 |
C91.61 |
C91.62 |
C91.90 |
C91.91 |
C91.92 |
C91.A0 |
C91.A1 |
C91.A2 |
C91.Z0 |
C91.Z1 |
C91.Z2 |
C92.00 |
C92.01 |
C92.02 |
C92.10 |
C92.11 |
C92.12 |
C92.20 |
C92.21 |
C92.22 |
C92.30 |
C92.31 |
C92.32 |
C92.40 |
C92.41 |
C92.42 |
C92.50 |
C92.51 |
C92.52 |
C92.60 |
C92.61 |
C92.62 |
C92.90 |
C92.91 |
C92.92 |
C92.A0 |
C92.A1 |
C92.A2 |
C92.Z0 |
C92.Z1 |
C92.Z2 |
|
|
|
|
|
|
Non-Covered Diagnosis Codes for Procedure Code: 38242
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.390 |
C83.398 |
C83.50 |
C83.51 |
C83.52 |
C83.53 |
C83.54 |
C83.55 |
C83.56 |
C83.57 |
C83.58 |
C83.59 |
C83.70 |
C83.71 |
C83.72 |
C83.73 |
C83.74 |
C83.75 |
C83.76 |
C83.77 |
C83.78 |
C83.79 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C83.90 |
C83.91 |
C83.92 |
C83.93 |
C83.94 |
C83.95 |
C83.96 |
C83.97 |
C83.98 |
C83.99 |
C84.40 |
C84.41 |
C84.42 |
C84.43 |
C84.44 |
C84.45 |
C84.46 |
C84.47 |
C84.48 |
C84.49 |
C84.60 |
C84.61 |
C84.62 |
C84.63 |
C84.64 |
C84.65 |
C84.66 |
C84.67 |
C84.68 |
C84.69 |
C84.70 |
C84.71 |
C84.72 |
C84.73 |
C84.74 |
C84.75 |
C84.76 |
C84.77 |
C84.78 |
C84.79 |
C84.90 |
C84.91 |
C84.92 |
C84.93 |
C84.94 |
C84.95 |
C84.96 |
C84.97 |
C84.98 |
C84.99 |
C84.A0 |
C84.A1 |
C84.A2 |
C84.A3 |
C84.A4 |
C84.A5 |
C84.A6 |
C84.A7 |
C84.A8 |
C84.A9 |
C84.Z0 |
C84.Z1 |
C84.Z2 |
C84.Z3 |
C84.Z4 |
C84.Z5 |
C84.Z6 |
C84.Z7 |
C84.Z8 |
C84.Z9 |
C85.10 |
C85.11 |
C85.12 |
C85.13 |
C85.14 |
C85.15 |
C85.16 |
C85.17 |
C85.18 |
C85.19 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C85.90 |
C85.91 |
C85.92 |
C85.93 |
C85.94 |
C85.95 |
C85.96 |
C85.97 |
C85.98 |
C85.99 |
C86.00 |
C86.01 |
C86.10 |
C86.11 |
C86.20 |
C86.21 |
C86.30 |
C86.31 |
C86.40 |
C86.41 |
C86.50 |
C86.51 |
C86.60 |
C86.61 |
C88.40 |
C88.41 |
D46.0 |
D46.1 |
D46.20 |
D46.21 |
D46.22 |
D46.4 |
D46.9 |
D46.A |
D46.B |
D46.C |
D46.Z |
F84.0 |
F84.3 |
F84.5 |
F84.8 |
F84.9 |
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:
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.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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:
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.
