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Effective Date: 07/11/2013 |
Title: HDC & Autologous Stem and/or Progenitor Cell Support - Non-Hodgkin`s Lymphomas
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Revision Date:
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Document: BI415:00
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CPT Code(s): 38230, 38240-38242
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
High Dose
Chemotherapy and stem cell transplant requires pre-authorization.
Autologous
stem cell transplants are covered for selected patients with non Hodgkin’s
lymphoma.
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Medical Statement
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High dose chemotherapy with autologous bone marrow, stem cell or progenitor cell
support for treatment of non-Hodgkin`s lymphoma (NHL) is considered medically
necessary and is covered:
International Working Formulation (IWF) subtypes intermediate or aggressive:
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as
salvage therapy for patients who do not achieve a complete remission
(CR) after first-line treatment (induction) with a full course of
standard-dose chemotherapy;
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to
consolidate a first complete response for patients with an age-adjusted
International Prognostic Index score that predicts a high- or
high-intermediate risk of relapse; and
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to
achieve or consolidate CR for those in a chemosensitive first or
subsequent relapse.
For patients with NHL subtypes the IWF scheme classified as indolent, and for
new subtypes defined by the World Health Organization/Revised European American
Lymphoma scheme
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as
salvage therapy for patients who do not achieve a complete remission
(CR) after first-line treatment (induction) with a full course of
standard-dose chemotherapy;
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to
achieve or consolidate CR for those in a first or subsequent
chemosensitive relapse, whether or not their lymphoma has undergone
transformation to a higher grade.
Codes Used In This BI:
38230, Bone
marrow harvesting for transplantation
38240, Bone
marrow or blood-derived peripheral stem cell transplantation; allogenic
38241, Bone
marrow or blood-derived peripheral stem cell transplantation; autologous
38242, Bone
marrow or blood-derived peripheral stem cell transplantation; allogeneic donor
lymphocyte infusions
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Limits
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High dose chemotherapy with allogeneic stem and/or progenitor cell support is
not covered following autologous stem and/or progenitor cell transplantation.
Tandem high dose chemotherapy with autologous stem and/or progenitor cell
support is not covered for any diseases other than multiple myeloma and
Waldenstrom’s macroglobulinemia.
A second or subsequent course of high dose chemotherapy with allogeneic or
autologous stem cell and/or progenitor cell support for treatment of relapsed
disease is covered only for patients who have shown a complete response to the
initial high dose chemotherapy/transplant regimen.
Coverage of high dose chemotherapy with allogeneic or autologous stem and/or
progenitor cell support for a patient with two active malignant diseases is
covered only if both diseases have a specific coverage policy and the patient
meets all criteria for both high dose chemotherapy with stem and/or progenitor
cell treatment regimens.
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Background
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The available evidence suggested that, based on total tumor response rates and complete response rates in patients with intermediate or high-grade lymphomas, the use of HDC with autologous stem-cell support produced outcomes comparable to salvage therapy for intermediate- and high-grade lymphomas.
The rationale for HDC and allogeneic stem-cell support in intermediate or high-grade lymphomas was based on the success seen with HDC and autologous stem-cell support, where the estimated 3- to 5-year survival was 40%–60%. However, some patients were not candidates for autologous stem-cell support due to chronic marrow hypocellularity or malignancy involving the bone marrow. Allogeneic stem-cell support provided an alternative. The data suggested that the 3- to 5-year survival rates associated with allogeneic stem-cell support were comparable to those associated with autologous stem-cell support.
o Data were minimal concerning outcomes of allogeneic stem-cell support, and most reports focused on outcomes of HDC without regard to the source of stem cells. Thus, the literature reviewed only compared outcomes after HDC supported by any source of stem cells to outcomes after conventional-dose regimens. Whether there was a treatment advantage for allogeneic or autologous stem-cell support was unknown.
o Data were inadequate to compare outcomes of high-dose therapy plus either allogeneic or autologous stem-cell support with conventional-dose alternatives for patients with low-grade or follicular NHL either as primary therapy or as salvage therapy after relapse and transformation to a higher grade NHL histology.
Sufficient data were reported to assess outcomes of HDC as salvage therapy for low-grade follicular lymphoma that had failed primary treatment without transformation to a higher grade. In this group of patients, the disease-free survival at 5 years was 10%–66% after HDC and only 2%–21% after conventional-dose alternatives. Given the natural history of this indolent disease, which is one of repeated relapses and progressively shorter durations of remission, improvement in disease-free survival was considered a good predictor of improvement in overall survival.
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Reference
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1987 Blue Cross Blue Shield Association Technology Evaluation Center Assessment;
p 61.
1990 Blue Cross Blue Shield Association Technology Evaluation Center Assessment;
p 178.
1995 Blue Cross Blue Shield Association Technology Evaluation Center Assessment;
Tab 28.
2000 Blue Cross Blue Shield Association Technology Evaluation Center Assessment;
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Berglund A, Enblad G, Carlson K, et al.(2000) Long-term follow-up of autologous
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Bierman PJ, Vose JM, Anderson JR, et al.(1997) High-dose therapy with autologous
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Blystad AK, Enblad G, Kvaloy S, et al.(2001) High-dose therapy with autologous
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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