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.

Transplantation of stem cells, whether derived from bone marrow, peripheral blood, or umbilical cord blood, requires preauthorization.  This limitation applies to the transplantation and any related procedure including high dose chemotherapy.  Coverage is provided only for specific indications.

Transplants and transplant related services are covered only when performed at a transplant center previously approved by QualChoice.

High dose chemotherapy and allogeneic stem cell transplantation requires prior authorization and is covered for the following indications:

1)    Non-malignant disorders

a)    Aplastic anemia, congenital or acquired

i)     For patients with severe thrombocytopenia, severe granulocytopenia, reticulocyte count less than 1% corrected for anemia, and who have failed antithymocyte globulin therapy

b)    Wiscott-Aldrich syndrome

c)    Albers-Schonberg syndrome

d)    Hemoglobinopathy

i)     Homozygous Beta-thalassemia

ii)    Sickle cell anemia for children or young adults with either a history of prior stroke or at increased risk of stroke or end-organ damage, and with an HLA-identical related donor

e)    Severe combined immunodeficiency’s

f)     Hematophagocytic  lymphocytosis

g)    Paroxysmal nocturnal hemoglobinuria

2)    Myelodysplastic syndromes

a)    For selected IPSS intermediate-1 prognostic score patients who meet NCCN guidelines

b)    For IPSS intermediate-2 or high prognostic category patients

3)    Non-Hodgkin lymphoma

a)    Diffuse large B-cell lymphoma

i)     For patients with partial or complete response to therapy

b)    Chronic lymphocytic leukemia/small lymphocytic lymphoma

i)     When the patient is determined to be a candidate according to NCCN Guideline CLL/SLL

c)    Burkitt lymphoma

i)     For relapse after complete response to first line chemotherapy

d)    Peripheral T cell lymphomas

i)     After complete or partial response to second line therapy after relapse

e)    Adult T-cell leukemia/lymphoma

i)     For responders to first or second line therapy

f)     Extranodal NK/T-cell lymphoma, nasal type

i)     For patients with stage I nasal disease after RT with partial response or refractory disease after salvage chemotherapy

ii)    For patients with stage II or IV nasal disease after RT with complete or partial response

iii)   For patients with extranasal disease with complete or partial response

g)    T-cell prolymphocytic leukemia

i)     After complete or partial response to first line therapy

4)    Chronic myelogenous leukemia

a)    For first line treatment in patients in blast phase at diagnosis, patients with T3151 or other BCR-ABL mutations resistant to all tyrosine kinase inhibitors, or for patients intolerant to all TKIs

b)    For patients with disease progression to accelerated or blast phase on TKI therapy

c)    NOTE:  stem cell transplant is no longer considered first line therapy for patients in chronic phase CML, with the exceptions noted above

d)    Donor lymphocyte infusion (DLI) is covered for relapse following allogeneic stem cell transplant

5)    Multiple myeloma

a)    (for mini-allo after initial auto, or mini-allo as salvage as part of trial—look at NCCN)

6)    Acute lymphoblastic leukemia

a)    After first complete remission in patients at high risk of relapse

b)    Following second or greater remission

c)    For refractory ALL

7)    Donor lymphocyte infusion (DLI) is covered for relapse following allogeneic stem cell transplant.

8)    Acute myeloid leukemia

a)    Acute promyelocytic leukemia

i)     After first relapse, when a second remission cannot be achieved

ii)    In second remission, if PCR positive

b)    Acute myeloid leukemia age <60

i)     After failure of primary induction

ii)    In first remission, if intermediate or poor risk cytogenetics

iii)   As salvage therapy after first relapse

c)    Acute myeloid leukemia age ≥60

i)     After failure of primary induction (reduced intensity stem cell transplant)

ii)    After complete response to induction

iii)   As salvage therapy after first relapse

Codes Used In This BI:

38230             Bone marrow harvesting for transplant; allogeneic

38240             Hematopoietic progenitor cell, allogeneic transplantation, per donor

38242             Allogeneic donor lymphocyte infusions

1)    Any other use of allogeneic stem cell transplant is considered experimental and/or investigational, and is not covered.

2)    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.

3)    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.

4)    Each course of high dose chemotherapy with autologous or allogeneic stem cell transplantation is considered to be one transplant for purposes of any coverage limits.

National Comprehensive Cancer Network.  NCCN Guidelines Version 1.2014