Medical Policy

Effective Date:01/01/2014	Title:High Dose Chemotherapy & Autologous Stem Cell Transplant
Revision Date:09/01/2016	Document:BI438:00
CPT Code(s):38232, 38241, 38243
Public Statement
*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. Tandem autologous stem cell transplant is not covered for any diseases other than multiple myeloma, Waldenstron’s Macroglobulinemia, amyloidosis and recurrent germ cell tumors.
Medical Statement
High dose chemotherapy and autologous stem cell transplantation is covered for the following indications: 1) Non-Hodgkin lymphoma a) Diffuse large B-cell lymphoma i) For patients with partial or complete response to therapy b) Mantle cell lymphoma i) For first line consolidation 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 2) Hodgkin lymphoma a) For patients with relapsed or refractory classical Hodgkin lymphoma b) Not covered for lymphocyte predominant Hodgkin lymphoma 3) Neuroblastoma a) For initial treatment of high-risk peripheral neuroblastoma 4) Multiple myeloma a) Single or tandem, for primary therapy or at relapse 5) Acute myeloid leukemia a) Acute promyelocytic leukemia i) In second remission, if PCR negative b) Acute myeloid leukemia age <60 i) In first remission, if better risk or intermediate risk cytogenetics 6) Amyloidosis a) For patients when amyloid deposits have resulted in significant organ dysfunction in no more than 2 organs, and the patient’s cardiac ejection fraction is at least 45% if there is cardiac involvement 7) Waldenstron’s macroglobulinemia a) Autologous stem cell transplantation is covered for newly diagnosed, chemotherapy responsive or relapsed disease or as salvage therapy. b) Tandem high dose chemotherapy with autologous stem-cell support is covered. Only two courses of therapy given in tandem are covered; each course is considered to be one transplant. 8) Adult Medulloblastoma and Supratentorial PNET a) For patients with localized brain recurrence, if the patient is without evidence of disease after surgery or conventional dose re-induction chemotherapy 9) Germ cell tumors a) Pure seminomas i) For progressive disease after first line chemotherapy b) Non-seminoma germ cell tumors i) For early (<2 years) relapse after complete response to first line chemotherapy, in patients with favorable prognosis ii) For late relapse after complete response to first line chemotherapy, if not resectable Codes Used In This BI: 38232 Bone marrow harvesting for transplant; autologous 38241 Hematopoietic progenitor cell, autologous transplantation 38243 Hematopoietic progenitor cell, boost
Limits
1) 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. 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.
Reference
Ghobrial IM, Gertz MA, Fonseca R. (2003) Waldenstrom Macroglobulinemia. Lancet Oncol 2003; 4:679-85. Munshi NC, Barlogie B.(2003) Role for high-dose therapy with autologous hematopoietic stem cell support in Waldenstrom`s Macroglobulinemia. Semin Oncol 2003; 30:282-5. Gertz MA, Anagnostopoulos A, et al. (2003) Treatment recommendations for Waldenstrom`s Macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldnstrom`s Macroglobulinemia. Semin Oncol 2003; 30:121-6. Lazarus HM, Loberiza FR, Zhang MJ, et al. (2001) Auto transplants for Hodgkin’s disease in first relapse or second remission: a report from the autologous blood and marrow transplant registry (ABMTR). BMT 2001; 27(4):387-96. Lin TS, Avalos BR, Penza SL, et al. (2002) second autologous stem cell transplant for multiply relapsed Hodgkin’s disease. BMT 2002; 29(9):763-7. Schmitz N, Pfistner B, Sextro M, et al.(2002) Aggressive conventional chemotherapy compared with high dose chemotherapy with autologous hematopoietic stem cell transplantation for relapsed chemo sensitive Hodgkin’s disease: a randomized trial. Lancet 2002; 359(9323):2065-71. Perfetti V, et al. Long-term results of a risk-adapted approach to Melphalan conditioning in autologous peripheral blood stem cell transplantation for primary (AL) amyloidosis. Haematologica 2006; 91:1635-1643.
Application to Products
This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

Ghobrial IM, Gertz MA, Fonseca R. (2003) Waldenstrom Macroglobulinemia. Lancet Oncol 2003; 4:679-85. Munshi NC, Barlogie B.(2003) Role for high-dose therapy with autologous hematopoietic stem cell support in Waldenstrom`s Macroglobulinemia. Semin Oncol 2003; 30:282-5.

Ghobrial IM, Gertz MA, Fonseca R. (2003) Waldenstrom Macroglobulinemia. Lancet Oncol 2003; 4:679-85.

Munshi NC, Barlogie B.(2003) Role for high-dose therapy with autologous hematopoietic stem cell support in Waldenstrom`s Macroglobulinemia. Semin Oncol 2003; 30:282-5.