hematopoietic stem-cell transplantation for chronic lymphocytic

Status
Active
Medical and Behavioral Health Policy
Section: Medicine
Policy Number: II-122
Effective Date: 04/22/2015
Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services
based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are
responsible for medical advice and treatment of patients. Members with specific health care needs should consult an
appropriate health care professional.
HEMATOPOIETIC STEM-CELL TRANSPLANTATION
FOR CHRONIC LYMPHOCYTIC LEUKEMIA
AND SMALL LYMPHOCYTIC LYMPHOMA
Description:
Hematopoietic stem-cell transplantation (HSCT) refers to a
procedure in which hematopoietic stem cells are infused to restore
bone marrow function in cancer patients who receive bone marrowtoxic doses of cytotoxic drugs, with or without whole-body radiation
therapy. Stem cells from bone marrow may be obtained from the
transplant recipient (autologous HSCT) or from a donor (allogeneic
HSCT). They can be harvested from bone marrow, peripheral
blood, or umbilical cord blood and placenta shortly after delivery of
neonates.
Chronic Lymphocytic Leukemia and Small Lymphocytic
Lymphoma
Chronic lymphocytic leukemia (CLL) and small lymphocytic
lymphoma (SLL) are neoplasms of hematopoietic origin
characterized by the accumulation of lymphocytes with a mature,
generally well-differentiated morphology. In CLL, these cells
accumulate in blood, bone marrow, lymph nodes, and spleen, while
in SLL they are generally confined to lymph nodes. The Revised
European-American/WHO Classification of Lymphoid Neoplasms
considers B-cell CLL and SLL a single disease entity.
CLL and SLL share many common features and are often referred to
as blood and tissue counterparts of each other, respectively. Both
tend to occur in older individuals and present as asymptomatic
enlargement of the lymph nodes. Both tend to be indolent in nature
but can undergo transformation to a more aggressive form of
disease (e.g., Richter’s transformation).
Definitions:
Myeloablation: The severe or complete depletion of bone marrow
cells, resulting from administration of high doses of chemotherapy or
radiation therapy prior to bone marrow transplantation.
Reduced-Intensity Conditioning for Allogeneic HSCT:
Reduced-intensity conditioning (RIC) refers to the pretransplant use
of lower doses or less intense regimens of cytotoxic drugs or
radiation than are used in conventional full-dose myeloablative
conditioning treatments. The goal of RIC is to reduce disease
burden, but also to minimize as much as possible associated
treatment-related morbidity and nonrelapse mortality (NRM) in the
period during which the beneficial graft versus malignancy (GVM)
effect of allogeneic transplantation develops. For the purposes of
this Policy, the term “reduced-intensity conditioning” will refer to all
conditioning regimens intended to be nonmyeloablative, as opposed
to fully myeloablative (conventional) regimens.
Policy:
Coverage:
I.
Allogeneic Hematopoietic Stem-Cell Transplantation
A. Allogeneic hematopoietic stem-cell transplantation may be
considered MEDICALLY NECESSARY to treat chronic
lymphocytic leukemia or small lymphocytic lymphoma in
patients with markers of high-risk disease, as defined by
one of the classification systems used to determine stage
and prognosis of patients with CLL/SLL (Rai staging system
or Binet classification system). Use of a myeloablative or
reduced-intensity pretransplant conditioning regimen should
be individualized based on factors that include patient age,
the presence of comorbidities, and disease burden.
B. Allogeneic hematopoietic stem-cell transplantation is
considered INVESTIGATIVE to treat chronic lymphocytic
leukemia or small lymphocytic lymphoma when the criteria
above are not met.
II.
Autologous Hematopoietic Stem-Cell Transplantation
A. Autologous hematopoietic stem-cell transplantation is
considered INVESTIGATIVE to treat chronic lymphocytic
leukemia or small lymphocytic lymphoma.
Blue Cross and Blue Shield of Minnesota medical policies apply
generally to all Blue Cross and Blue Plus plans and products. Benefit
plans vary in coverage and some plans may not provide coverage
for certain services addressed in the medical policies.
Medicaid products and some self-insured plans may have additional
policies and prior authorization requirements. Receipt of benefits is
subject to all terms and conditions of the member’s summary plan
description (SPD). As applicable, review the provisions relating to a
specific coverage determination, including exclusions and limitations.
Blue Cross reserves the right to revise, update and/or add to its
medical policies at any time without notice.
For Medicare NCD and/or Medicare LCD, please consult CMS or
National Government Services websites.
Refer to the Pre-Certification/Pre-Authorization section of the
Medical Behavioral Health Policy Manual for the full list of services,
procedures, prescription drugs, and medical devices that require
Pre-certification/Pre-Authorization. Note that services with specific
coverage criteria may be reviewed retrospectively to determine if
criteria are being met. Retrospective denial of claims may result if
criteria are not met.
Coding:
The following codes are included below for informational purposes
only, and are subject to change without notice. Inclusion or exclusion
of a code does not constitute or imply member coverage or provider
reimbursement.
CPT:
38204 Management of recipient hematopoietic progenitor cell donor
search and cell acquisition
38205 Blood-derived hematopoietic progenitor cell harvesting for
transplantation, per collection; allogeneic
38206 Blood-derived hematopoietic progenitor cell harvesting for
transplantation, per collection; autologous
38207 Transplant preparation of hematopoietic progenitor cells;
cryopreservation and storage
38208 Transplant preparation of hematopoietic progenitor cells;
thawing of previously frozen harvest, without washing, per donor
38209 Transplant preparation of hematopoietic progenitor cells;
thawing of previously frozen harvest, with washing, per donor
38210 Transplant preparation of hematopoietic progenitor cells;
specific cell depletion within harvest, T-cell depletion
38211 Transplant preparation of hematopoietic progenitor cells;
tumor cell depletion
38212 Transplant preparation of hematopoietic progenitor cells; red
blood cell removal
38213 Transplant preparation of hematopoietic progenitor cells;
platelet depletion
38214 Transplant preparation of hematopoietic progenitor cells;
plasma (volume) depletion
38215 Transplant preparation of hematopoietic progenitor cells; cell
concentration in plasma, mononuclear, or buffy coat layer
38220 Bone marrow; aspiration only
38221 Bone marrow; biopsy, needle or trocar
38230 Bone marrow harvesting for transplantation; allogeneic
38232 Bone marrow harvesting for transplantation; autologous
38240 Hematopoietic progenitor call (HPC); allogeneic
transplantation per donor
38241 Hematopoietic progenitor call (HPC); autologous
transplantation
38242 Allogeneic lymphocyte infusions
38243 Hematopoietic progenitor call (HPC); HPC boost
HCPCS:
G0364 Bone marrow aspiration performed with bone marrow biopsy
through the same incision on the same date of service
S2140 Cord blood harvesting for transplantation, allogeneic
S2142 Cord blood-derived stem-cell transplantation, allogeneic
S2150 Bone marrow or blood-derived stem cells (peripheral or
umbilical), allogeneic or autologous, harvesting, transplantation, and
related complications including pheresis and cell
preparation/storage; marrow ablative therapy; drugs, supplies,
hospitalization with outpatient follow-up; medical/surgical, diagnostic,
emergency, and rehabilitative services; and the number of days of
pre- and posttransplant care in the global definition
ICD-9 Procedure:
41.00 Bone marrow transplant, not otherwise specified
41.01 Autologous bone marrow transplant without purging
41.02 Allogeneic bone marrow transplant with purging
41.03 Allogeneic bone marrow transplant without purging
41.04 Autologous hematopoietic stem cell transplant without purging
41.05 Allogeneic hematopoietic stem cell transplant without purging
41.06 Cord blood stem cell transplant
41.07 Autologous hematopoietic stem cell transplant with purging
41.08 Allogeneic hematopoietic stem cell transplant with purging
41.09 Autologous bone marrow transplant with purging
41.31 Biopsy of bone marrow
41.91 Aspiration of bone marrow from donor for transplant
41.98 Other operations on bone marrow
99.79 Transfusion of blood and blood components; other
ICD-10 Procedure:
07DQ0ZX Extraction of Sternum Bone Marrow, Open Approach,
Diagnostic
07DQ3ZX Extraction of Sternum Bone Marrow, Percutaneous
Approach, Diagnostic
07DQ3ZZ Extraction of Sternum Bone Marrow, Percutaneous
07DR0ZX Extraction of Iliac Bone Marrow, Open Approach,
Diagnostic
07DR3ZX Extraction of Iliac Bone Marrow, Percutaneous Approach,
Diagnostic
07DS0ZX Extraction of Vertebral Bone Marrow, Open Approach,
Diagnostic
07DS3ZX Extraction of Vertebral Bone Marrow, Percutaneous
Approach, Diagnostic
30233G0 Transfusion of Autologous Bone Marrow into Peripheral
Vein, Percutaneous Approach
30233G1 Transfusion of Nonautologous Bone Marrow into
Peripheral Vein, Percutaneous Approach
30233X0 Transfusion of Autologous Cord Blood Stem Cells into
Peripheral Vein, Percutaneous Approach
30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into
Peripheral Vein, Percutaneous Approach
30233Y1 Transfusion of Nonautologous Hematopoietic Stem Cells
into Peripheral Vein, Percutaneous Approach
30243G0 Transfusion of Autologous Bone Marrow into Central Vein,
Percutaneous Approach, and 3E04305 Introduction of Other
Antineoplastic into Central Vein, Percutaneous Approach
30243G1 Transfusion of Nonautologous Bone Marrow into Central
Vein, Percutaneous Approach, and 3E05305 Introduction of Other
Antineoplastic into Peripheral Artery, Percutaneous Approach
30243Y0 Transfusion of Autologous Hematopoietic Stem Cells into
Central Vein, Percutaneous Approach, and 3E04305 Introduction of
Other Antineoplastic into Central Vein, Percutaneous Approach
30243Y1 Transfusion of Nonautologous Hematopoietic Stem Cells
into Central Vein, Percutaneous Approach, and 3E04305
Introduction of Other Antineoplastic into Central Vein, Percutaneous
Approach
6A550ZT Pheresis of Cord Blood Stem Cells, Single
6A550ZV Pheresis of Hematopoietic Stem Cells, Single
6A551ZT Pheresis of Hematopoietic Stem Cells, Multiple
6A551ZV Pheresis of Cord Blood Stem Cells, Multiple
Policy
History:
Developed October 14, 2009
Most recent history:
Reviewed May 9, 2012
Reviewed/Updated, no policy statement changes May 8, 2013
Reviewed April 9, 2014
Reviewed April 8, 2015
Cross
Reference:
Current Procedural Terminology (CPT®) is copyright 2014 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative values, or
related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
Copyright 2015 Blue Cross Blue Shield of Minnesota.