Print

Date Printed: September 23, 2014: 08:19 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2014, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. 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. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-38241-01

Original Effective Date: 08/15/02

Reviewed: 09/26/13

Revised: 10/15/13

Subject: Autologous Bone Marrow and Stem Cell Transplantation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    

DESCRIPTION:

Hematopoietic Stem-Cell Transplantation

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-marrow-toxic doses of cytotoxic drugs, with or without whole-body radiation therapy. Bone marrow stem cells may be obtained from the transplant recipient (i.e., autologous HSCT) or from a donor (i.e., allogeneic HSCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates. Although cord blood is an allogeneic source, the stem cells in it are antigenically “naïve” and thus are associated with a lower incidence of rejection or graft-versus-host disease (GVHD).

Immunologic compatibility between infused stem cells and the recipient is not an issue in autologous HSCT. However, immunologic compatibility between donor and patient is a critical factor for achieving a good outcome of allogeneic HSCT. Compatibility is established by typing of human leukocyte antigens (HLA) using cellular, serologic, or molecular techniques. HLA refers to the tissue type expressed at the HLA A, B, and DR loci on each arm of chromosome 6. Depending on the disease being treated, an acceptable donor will match the patient at all or most of the HLA loci.

The success of autologous HSCT is predicated on the ability of cytotoxic chemotherapy with or without radiation to eradicate cancerous cells from the blood and bone marrow. This permits subsequent engraftment and repopulation of bone marrow space with presumably normal hematopoietic stem cells obtained from the patient prior to undergoing bone marrow ablation. As a consequence, autologous HSCT is typically performed as consolidation therapy when the patient’s disease is in complete remission. Patients who undergo autologous HSCT are susceptible to chemotherapy-related toxicities and opportunistic infections prior to engraftment, but not GVHD.

POSITION STATEMENT:

REQUIRED: Certificate of Medical Necessity

NOTE: Submitting a completed Certificate of Medical Necessity with your request for Autologous Bone Marrow and Stem Cell Transplantation is required.

Click the link below to open the form. Complete all fields on the form thoroughly. Print and submit a copy of the form with your faxed request.

In accordance with Chapter 59-B of the Florida Administrative Code [(1) – (5)]:

(1) Autologous hematopoietic stem cell transplantation meets the definition of medical necessity when performed for one of the following indications:

In cases where treatment for any of the above conditions includes a clinical trial that conforms to subsection (5) (below), routine care costs associated with the bone marrow transplant will be covered.

(2) Autologous hematopoietic stem cell transplantation meets the definition of medical necessity for the following indications when the bone marrow transplantation procedure is performed in the context of a well-designed and conducted Phase II or Phase III clinical treatment trial:

(3) The following rare diseases, where there are no existing clinical trials available, are covered for bone marrow transplant at the Blood and Marrow Transplant Clinical Trials Network (BMT CNT) core or non-core facilities when deemed medically necessary:

(4) Any bone marrow transplant performed outside of a clinical trial will be covered when all the following criteria are met:

(5) A well-designed and conducted clinical treatment trial is one which includes an IRB-approved written protocol. At a minimum, such protocol shall have specific criteria for evaluating the effect of treatment with defined endpoints that are precise, meaningful, and reliable and which allow valid conclusions to be drawn about therapeutic efficacy and safety. Protocols should include an adequate statistical section describing the method of randomization and stratification, if any, expected outcome parameters relating to response rates, time to progression, survival times and other relevant information. Such clinical treatment trials shall be consistent with protocols reviewed and approved by the National Cancer Institute for scientific merit.

Autologous hematopoietic stem cell transplantation also meets the definition of medical necessity when performed for one of the following indications:

It should be noted that there are non-malignant diseases that are genetic disorders or that result in bone marrow failure or lead to immunodeficiency syndromes for which bone marrow transplantation may be appropriate. While these non-malignant diseases are not described in the preceding lists, there are generally accepted and appropriate indications for bone marrow transplantation in these cases. In addition, there are malignant diseases that are uncommon in their occurrence that also are not included in the above lists for which the appropriateness of bone marrow transplantation may be determined on a case by case basis.

Autologous bone marrow transplantation administered with high dose chemotherapy for all other indications is considered experimental or investigational, as there is insufficient scientific evidence to establish definite conclusions regarding the efficacy of autologous stem cell transplantation and specifically for the following indications:

  1. Solid tumors in adults (e.g., lung, colon, rectal, pancreas, stomach, bile duct, esophageal, gallbladder, renal cell, cervical, ovary, uterine, fallopian tube, prostate, nasopharyngeal, paranasal, thyroid, thymus, tumors of unknown primary origin)
  2. Autoimmune diseases such as multiple sclerosis, juvenile idiopathic and rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis/scleroderma, Crohns disease; chronic inflammatory demyelinating polyneuropathy (CIDP), immune cytopenias, relapsing polychondritis or type I diabetes mellitus
  3. Tandem autologous transplantation (i.e., two courses of HDC) for breast cancer.
  4. Malignant astrocytoma and glioma (including glioblastoma multiforme and oilgodendroglioma)
  5. Chronic myelogenous leukemia

Processing, cryopreservation, storage and thawing of peripheral stem cells is eligible for coverage if the harvesting and transplantation is covered.

Harvesting (bone marrow and peripheral stem cells) and cryopreservation (storage) services are eligible for coverage when a bone marrow transplant has been identified by the physician as a course of treatment and is planned or anticipated in the future.

Prophylactic collection and storage of cord blood from a neonate is considered not medically necessary when proposed for some unspecified future use as an autologous stem-cell transplant in the original donor, or for some unspecified future use as an allogeneic stem-cell transplant in a related or unrelated donor.

BILLING/CODING INFORMATION:

CPT Coding:

38204

Management of recipient hematopoietic progenitor cell donor search and cell acquisition

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, buffy coat layer

38220

Bone marrow aspiration; only

38232

Bone marrow, aspiration only, autologous

38241

Hematopoietic progenitor cell (HPC); autologous transplantation

HCPCS Coding:

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 day of pre- and post-transplant care in the global definition (non-covered)

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical including previous transplants, physician progress notes, treatment plan, radiology report(s), operative and/or pathology report(s), laboratory studies, medication history, type of transplant and reason for transplant, smoking/alcohol/drug abuse history, cardiac and pulmonary clearances, psychosocial assessment and all diagnostic testing.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Laboratory studies

26436-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Transplant Rx

22043-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Transplant Rx at facility

21883-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Transplant risk factors

44758-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Reason for transplant

44756-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

History of tobacco use

11366-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Alcohol abuse

42830-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Drug abuse

42831-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Cardiac screen assessment

39257-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pulmonary consultation note

34103-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Psychosocial well-being, addressed in care plan

58168-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Diagnostic studies (non-lab)

27899-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Processing, cryopreservation, storage and thawing of autologous bone marrow is eligible for coverage if the harvesting and transplantation are determined eligible for coverage. Reimbursement for these services is limited to the facility (e.g., hospital).

Processing, cryopreservation, storage and thawing of peripheral stem cells is eligible for coverage if the harvesting and transplantation is covered. All reimbursement is included in the outpatient (or inpatient) facility fee for the leukopheresis.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following National Coverage Determination (NCD) was reviewed on the last guideline revised date: Stem Cell Transplantation (110.8.1) located at cms.gov.

DEFINITIONS:

Acquired: not genetic, but produced by influences originating outside the organism.

Allogeneic: having a different genetic constitution, but belonging to the same species. Allogeneic stem cell support provides two theoretical advantages – (1) the lack of tumor contamination associated with the use of autologous stem cells and (2) the possibility of a beneficial graft vs. tumor effect.

Autologous bone marrow cells: stem cells are harvested from the patient’s own bone marrow prior to the cytotoxic therapy, then reinfused into the patient after the therapy.

Cryopreservation: preservation by subjection to extremely low temperatures.

Embryonal tumors of the central nervous system (CNS): Primarily composed of undifferentiated round cells, with divergent patterns of differentiation. It has been proposed that these tumors be merged under the term primitive neuroectodermal tumor (PNET); however, histologically similar tumors in different locations in the brain demonstrate different molecular genetic alterations. Central nervous system (CNS) embryonal tumors are more common in children and are the most common brain tumor in childhood.

HLA: special identifying markers that are on all cells of the body. HLA markers must match fairly closely between donor and patient, or rejection may occur. HLA identical means that two people have the same markers as each other (this can occur in twins or brothers and sisters).

Leukemia: “liquid” tumors; a type of white blood cell that grows uncontrollably. Names are given depending on which type of white blood cell is abnormal. More sudden types include Acute Lymphoblastic Leukemia (ALL), Acute Non-lymphocytic Leukemia (ANLL), and Acute Myelocytic Leukemia (AML). More gradual types include Chronic Granulocytic Leukemia (CGL), Chronic Myelogenous Leukemia (CML) Chronic Myelomonocytic Leukemia (CMML), and Chronic Lymphocytic Leukemia (CLL).

Lymphoma: tumor of the white blood cells called lymphocytes. Different types include Hodgkin’s, (Follicular) Non-Hodgkins (NHL), and Small Lymphocytic Lymphoma (SLL).

Myeloma: tumor of one of the types of white blood cells.

Stem cell support: a machine can separate only the most important cells (stem cells) from a bone marrow sample or blood sample (peripheral blood stem cells, PBSC), to be transplanted back into the same patient later, after treatment. The machine can also be used to remove cancerous stem cells and keep the normal cells. Stem cells can be collected from the bone marrow or from the peripheral blood.

Syngeneic: genetically identical especially with respect to antigens or immunological reactions. Refers to stem cells harvested from an identical twin.

Tandem transplant: two courses of high dose chemotherapy are given, opposed to the typical one course. Tandem transplants are typically administered at intervals of 2 – 6 months, depending on recovery from prior toxicity.

RELATED GUIDELINES:

Allogeneic Bone Marrow and Stem Cell Transplantation, 02-38240-01

OTHER:

Florida Statute 627.4236 Coverage for bone marrow transplant procedures (excerpt)

(1) As used in this section, the term “bone marrow transplant” means human blood precursor cells administered to a patient to restore normal hematological and immunological functions following ablative or nonablative therapy with curative or life-prolonging intent. Human blood precursor cells may be obtained from the patient in an autologous transplant or from a medically acceptable related or unrelated donor, and may be derived from bone marrow, circulating blood, or a combination of bone marrow and circulating blood. If chemotherapy is an integral part of the treatment involving bone marrow transplantation, the term “bone marrow transplant” includes both the transplantation and the chemotherapy.

(2) An insurer or a health maintenance organization may not exclude coverage for bone marrow transplant procedures recommended by the referring physician and the treating physician under a policy exclusion for experimental, clinical investigative, educational, or similar procedures contained in any individual or group health insurance policy or health maintenance organization contract issued, amended, delivered, or renewed in this state that covers treatment for cancer, if the particular use of the bone marrow transplant procedure is determined to be accepted within the appropriate oncological specialty and not experimental pursuant to subsection. (3) Covered bone marrow transplant procedures must include costs associated with the donor-patient to the same extent and limitations as costs associated with the insured, except the reasonable costs of searching for the donor may be limited to immediate family members and the National Bone Marrow Donor Program.

REFERENCES:

  1. Agency for Health Care Administration; Rules of the Department of Health and Rehabilitative Services, Chapter 59-B, Florida Administrative Code, Section 59-B-12.001 (09/26/00; amended 07/07/13). Accessed 07/15/13.
  2. AHRQ National Guideline Clearinghouse: Dose-intensive chemotherapy with growth factor or autologous bone marrow/stem cell transplant support in the first-line treatment of advanced or metastatic adult soft tissue sarcoma: a practice guideline. NGC-5006. Verma S, Younus J, Stys-Norman D, Haynes AE, Blackstein M, Sarcoma Disease Site Group. Dose-intensive chemotherapy with growth factor or autologous bone marrow/stem cell transplant support in the first-line treatment of advanced or metastatic adult soft tissue sarcoma: a practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Apr 11. 24 p. (Evidence-based series; no. 11-5).
  3. AHRQ National Guideline Clearinghouse: Guidelines for policies on alternatives to allogeneic blood transfusion. 1. Predeposit autologous blood donation and transfusion. NGC-6193. British Committee for Standards in Haematology, Transfusion Task Force, Boulton FE, James V. Guidelines for policies on alternatives to allogeneic blood transfusion. 1. Predeposit autologous blood donation and transfusion. Transfus Med 2007 Oct;17 (5):354-65.
  4. AHRQ National Guideline Clearinghouse: Guidelines on the management of acute myeloid leukaemia in adults. NGC-6225 British Committee for Standards in Haematology, Milligan DW, Grimwade D, Cullis JO, Bond L, Swirsky D, Craddock C, Kell J, Homewood J, Campbell K, McGinley S, Wheatley K, Jackson G. Guidelines on the management of acute myeloid leukaemia in adults. Br J Haematol. 2006 Nov;135 (4):450-74.
  5. AHRQ National Guideline Clearinghouse. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of diffuse large B cell lymphoma: update of the 2001 evidence-based review. NGC-8491. American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant. 2011 Jan;17(1): 18-9. (Accessed 07/29/13).
  6. AHRQ National Guideline Clearinghouse: Stem cell transplantation in adults: recommendations. NGC-7225 Imrie K, Rumble RB, Crump M, Advisory Panel on Bone Marrow and Stem Cell Transplantation, Hematology Disease Site Group. Stem cell transplantation in adults: recommendations. Toronto (ON): Cancer Care Ontario Program in Evidence-based Care; 01/30/09. (Accessed 07/10/13).
  7. AHRQ National Guideline Clearinghouse: Guidelines for policies on alternatives to allogeneic blood transfusion. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of myelodysplastic syndromes. Guideline Summary NGC-7415. Biol Blood Marrow Transplant 2009 Feb;15 (2):135-6.
  8. AHRQ National Guideline Clearinghouse: The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of acute myeloid leukemia in adults. Guideline Summary NGC-7416. Biol Blood Marrow Transplant 2008 Feb;14(2):135-6.
  9. AHRQ National Guideline Clearinghouse. Clinical management of myelodysplastic syndromes: update of SIE, SIES, GITMO practice guidelines. NGC-9596. Santini V, Alessandrino PE, Angelucci E, Barosi G, Billio A, Di Maio M, Finelli C, Locatelli F, Marchetti M, Morra E, Musto P, Visani G, Tura S, Italian Society of Hematology. Clinical management of myelodysplastic syndromes: update of SIE, SIES, GITMO practice guidelines. Leuk Res. 2010 Dec;34(12):1576-88. (Accessed 07/29/13).
  10. AHRQ National Guideline Clearinghouse. Stem cell transplantation in lymphoma. NGC-9685. Kouroukis CT, Rumble RB, Kuruvilla J, Crump M, Herst J, Hamm C. Stem cell transplantation in lymphoma. Toronto (ON): Cancer Care Ontario; 2012 Dec 13. (Accessed 07/29/13).
  11. American Medical Association CPT, (current edition).
  12. American Society for Bone and Marrow Transplantation (ASBMT) Guidelines, Policy Statements, and Reviews, (website accessed 08/11/09).
  13. Ayala E, Tomblyn M. Hematopoietic Cell Transplantation for Lymphoma. Cancer Control, October 2011, Vol. 18, No. 4.
  14. Bae SJ, Kang C et al. Iron Overload during Follow-up after Tandem High-Dose Chemotherapy and Autologous Stem Cell Transplantation in Patients with High-Risk Neuroblastoma. J Korean Med Sci 2012; 27: 363-369.
  15. Bassan R, et al. Improved risk classification for risk-specific therapy based on the molecular study of minimal residual disease (MRD) in adult acute lymphoblastic leukemia (ALL). BLOOD, 30 APRIL 2009, VOLUME 113, NUMBER 18.
  16. Beitinjaneh A, Saliba R, Okoroji G, Alousi AM, Popat UR, Korbling M, Anderlini P, Qazilbash M, Kebriaei P, Hosing C, Champlin RE, Khouri IF; University of Texas M. D. Anderson Cancer Center, Houston, TX. Autologous stem cell transplantation (ASCT) as upfront or salvage therapy for noncutaneous T-cell lymphoma (TCL): The University of Texas M. D. Anderson Cancer Center (MDACC) experience. 2011 ASCO Annual Meeting. General Poster Session, Leukemia, Myelodysplasia, and Transplantation. J Clin Oncol 29: 2011.
  17. Blue Cross Blue Shield Association Medical Policy Reference Manual – Policies 8.01.15 (01/13); 8.01.17 (04/12); 8.01.20 (02/13); 8.01.21 (11/12); 8.01.22 (09/12); 8.01.23 (11/12); 8.01.24 (10/12); 8.01.25 (09/12); 8.01.26 (08/12); 8.01.27 (01/13); 8.01.28 (11/12); 8.01.29 (11/12); 8.01.30 (12/12); 8.01.31 (09/12); 8.01.32 (05/13); 8.01.34 (04/13); 8.01.35 (04/13); 8.01.38 (05/08); 8.01.42 (02/13); 8.01.54 (02/13) .
  18. Campbell K, McGinley S, Wheatley K, Jackson G. Guidelines on the management of acute myeloid leukaemia in adults. Br J Haematol. 2006 Nov;135 (4):450-74.
  19. Centers for Medicaid and Medicare Services (CMS) Manual System, Pub 100-03, Section 110.8.1 Medicare National Coverage Determination for Stem Cell Transplantation, (08/04/10). Accessed 07/29/13.
  20. Cornelissen JJ, et al. Myeloablative allogeneic versus autologous stem cell transplantation in adult patients with acute lymphoblastic leukemia in first remission: a prospective sibling donor versus no-donor comparison. BLOOD, 5 FEBRUARY 2009 VOLUME 113, NUMBER 6.
  21. ECRI Institute Health Technology Forecast. Lymphoma (10/12/10).
  22. Florida Medicare Part B Medical Policy # 38230 – Stem Cell Transplantation, (policy retired 03/08/04).
  23. Florida State Statute 627.4236(3), (effective 01/00). Amended by House Bill 535 on June 10, 2008. (Accessed 07/29/13).
  24. Gökbuget N, et al. Adult patients with acute lymphoblastic leukemia and molecular failure display a poor prognosis and are candidates for stem cell transplantation and targeted therapies. BLOOD, 30 AUGUST 2012, VOLUME 120, NUMBER 9.
  25. Goldstone AH, et al. In adults with standard-risk acute lymphoblastic leukemia, the greatest benefit is achieved from a matched sibling allogeneic transplantation in first complete remission, and an autologous transplantation is less effective than conventional consolidation/maintenance chemotherapy in all patients: final results of the International ALL Trial (MRC UKALLXII/ECOG E2993). Blood. 2008 Feb 15;111(4):1827-33.
  26. Gotlib J. Hodgkin Lymphoma. The American Society of Hematology. 01/17/11.
  27. Gunnellini M, Emili R, Coaccioli S, Liberati A. The Role of Autologous StemCell Transplantation in the Treatment of Diffuse Large B-Cell Lymphoma. Advances in Hematology Volume 2012, Article ID 195484.
  28. InterQual 2011. CP:Procedures Adult ,Transplantation, Autologous Stem Cell. (Accessed 04/05/12).
  29. Khalafallah A, McDonnell K, Dawar HU, Robertson I, Woods D. Quality of Life Assessment in Multiple Myeloma Patients Undergoing Dose-Reduced Tandem Autologous Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2011, 3(1).
  30. Kosmas C, Athanasopoulos A, Politis P, Papachrysanthou T, Daladimos T, Papadaki A, Panagiotidi E, Moschovis D, Ziras N, Karabelis A, Mylonakis N; “Metaxa” Cancer Hospital, Pireaus, Greece. Successful autologous hematopoietic stem cell (AHSC) mobilization with salvage etoposide (VP16)-ifosfamide-platinum (VIP) followed by high-dose chemotherapy (HDC) and AHSC transplantation (AHSCT) in relapsed malignancies: preliminary single center experience. 2011 ASCO Annual Meeting. General Poster Session, Leukemia, Myelodysplasia, and Transplantation. J Clin Oncol 29: 2011.
  31. Laubach J, Richardson P, Munshi N, Anderson K. The Evolving Role of Autologous Stem Cell Transplantation in the Treatment of Multiple Myeloma. American Society of Hematology. 04/27/10.
  32. Lazarus HM, Advani AS. When, how, and what cell source for hematopoietic cell transplantation in first complete remission adult acute lymphoblastic leukemia? Hematology 2012.
  33. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Myelodysplastic Syndrome. Version 2.2014. Accessed at NCCN.org on 07/29/13.
  34. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Hodgkin Lymphoma. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  35. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Multiple Myeloma. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  36. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Non-Hodgkin’s Lymphomas. Version 1.2013. Accessed at NCCN.org on 07/29/13..
  37. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Acute Lymphoblastic Leukemia. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  38. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Acute Myeloid Leukemia. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  39. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Systemic Light Chain Amyloidosis. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  40. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Anal Carcinoma. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  41. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Bladder Cancer. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  42. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Bone Cancer. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  43. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3.2013. Accessed at NCCN.org on 07/29/13.
  44. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Cervical Cancer. Version 3.2013. Accessed at NCCN.org on 07/29/13.
  45. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Chronic Myelogenous Leukemia. Version 4.2013. Accessed at NCCN.org on 07/29/13.
  46. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Central Nervous System Cancers. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  47. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Colon Cancer. Version 3.2013. Accessed at NCCN.org on 07/29/13.
  48. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Dermatofibrosarcoma Protuberans. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  49. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Esophageal and Esophagogastric Junction Cancers. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  50. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Gastric Cancer. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  51. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Head and Neck Cancers. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  52. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Hepatobiliary Cancers. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  53. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Kidney Cancer. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  54. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Merkel Cell Carcinoma. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  55. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Melanoma. Version 1.2014. Accessed at NCCN.org on 07/29/13.
  56. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Malignant Pleural Mesothelioma. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  57. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Neuroendocrine Tumors. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  58. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Basal Cell and Squamous Cell Skin Cancers. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  59. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Non-Small Cell Lung Cancer. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  60. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Occult Primary. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  61. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Ovarian Cancer. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  62. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  63. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Penile Cancer. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  64. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Prostate Cancer. Version 4.2013. Accessed at NCCN.org on 07/29/13.
  65. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Rectal Cancer. Version 4.2013. Accessed at NCCN.org on 07/29/13.
  66. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Soft Tissue Sarcoma. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  67. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Small Cell Lung Cancer. Version 1.2014. Accessed at NCCN.org on 07/29/13.
  68. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Testicular Cancer. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  69. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Thyomas and Thymic Carcinomas. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  70. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Thyroid Carcinoma. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  71. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Uterine Neoplasms. Version 1.2013. Accessed at NCCN.org on 07/29/13.
  72. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Waldenstrom’s Macroglobulinemia / Lymphoplasmacytic Lymphoma. Version 2.2013. Accessed at NCCN.org on 07/29/13.
  73. Nishihori T, Alsina M. Advances in the Autologous and Allogeneic Transplantation. Strategies for Multiple Myeloma. Cancer Control October 2011, Vol. 18, No. 4.
  74. Michallet M, Dreger P et al. Autologous hematopoietic stem cell transplantation in chronic lymphocytic leukemia: results of European intergroup randomized trial comparing autografting versus observation. Blood 2011 117: 1516-1521.
  75. Moreb JS, Salmasinia D, Hsu J, Hou W, Cline C, Rosenau E. Long-TermOutcome after Autologous StemCell Transplantation with Adequate Peripheral Blood Stem Cell Mobilization Using Plerixafor and G-CSF in Poor Mobilizer Lymphoma and Myeloma Patients. Advances in Hematology Volume 2011, Article ID 517561.
  76. Park ES, Sung KW et al. Tandem High-Dose Chemotherapy and Autologous Stem Cell Transplantation in Young Children with Atypical Teratoid/Rhabdoid Tumor of the Central Nervous System. J Korean Med Sci 2012; 27: 135-140.
  77. Pavlu J, Szydlo RM, Goldman JM, Apperley JF. Three decades of transplantation for chronic myeloid leukemia: what have we learned? BLOOD, 20 JANUARY 2011, VOLUME 117, NUMBER 3.
  78. Peinemann F, Kroger N, Bartel C, Grouven U, Pittler M, et al. (2011). High-Dose Chemotherapy Followed by Autologous Stem Cell Transplantation for Metastatic Rhabdomyosarcoma—A Systematic Review. PLoS ONE 6(2): e17127.
  79. Pession A, Masetti R, Di Leo C, Franzoni M, Prete A. HLA-mismatched hematopoietic stem cell transplantation for pediatric solid tumors. Pediatric Reports 2011; 3(s2):e12.
  80. Ribera JM, et al. Comparison of intensive chemotherapy, allogeneic or autologous stem cell transplantation as post-remission treatment for adult patients with high-risk acute lymphoblastic leukemia. Results of the PETHEMA ALL-93 trial. Haematologica. 2005 Oct;90(10):1346-56.
  81. Richardson SE, McNamara C. The Management of Classical Hodgkin’s Lymphoma: Past, Present, and Future. Advances in Hematology Volume 2011, Article ID 865870.
  82. Rosiñol L, García-Sanz R et al on behalf of PETHEMA/Spanish Myeloma Group. Benefit from autologous stem cell transplantation in primary refractory myeloma? Different outcomes in progressive versus stable disease. Haematologica 2012; 97(4):616-621.
  83. Tyndall A. Successes and Failures of Stem Cell Transplantation in Autoimmune Diseases. American Society of Hematology. HEMATOPOIETIC STEMCELL TRANSPLANTATION I: TRANSPLANTATION IN BENIGN HEMATOLOGY. Hematology 2011.
  84. Voss MH, Feldman DR, Motzer RJ. High-dose chemotherapy and stem cell transplantation for advanced testicular cancer. Expert Rev Anticancer Ther. 2011 July; 11(7): 1091–1103.
  85. Wach M, Cioch M. Treatment of multiple myeloma patients with autologous stem cell transplantation: a fresh analysis. FOLIA HISTOCHEMICA ET CYTOBIOLOGICA Vol. 49, No. 2, 2011 pp. 248–254.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/26/13.

GUIDELINE UPDATE INFORMATION:

08/15/02

Medical Coverage Guideline Reformatted – Revised to reflect criteria set forth in Chapter 59-B of the Florida Administrative Code.

02/15/03

2003 HCPCS coding update.

08/15/03

Reviewed – no changes in coverage statement.

01/01/04

Annual HCPCS coding update.

04/01/04

2nd Quarter 2004 HCPCS coding update.

09/15/04

Scheduled review; no change in coverage statement.

01/01/05

HCPCS coding update: revised descriptor for S2150.

05/15/05

Revision consisting of addition of ICD-9 diagnosis code for primary amyloid light chain amyloidosis (277.3).

09/15/05

Scheduled review; expand list of covered indications to include metastatic malignant melanoma and multiple transplants for pediatric solid tumors.

09/15/06

Scheduled review; coverage statement revised to be consistent with Florida Administrative code 59B-12.

07/15/07

Scheduled review; reformatted guideline; updated references.

01/01/08

Annual HCPCS coding update: removed G0265, G0266, and G0267.

09/15/08

Scheduled review; revise position statement. Add excerpt from Florida Statute. Update references.

09/15/09

Scheduled review; update position statement and references.

10/15/10

Scheduled review; added ICD-10 codes added; revised to reflect criteria set forth in Chapter 59-B of the Florida Administrative Code, and; references updated; guideline reformatted.

09/15/11

Scheduled review; added Medicare program exception and updated references, formatting changes.

01/01/12

Annual HCPCS coding update. Added 38232. Revised 38208 and 38209 descriptors. Deleted 38230.

05/15/12

Revision; reformatted guideline.

06/15/12

Scheduled review. Revised description section and position statement. Added statement regarding cord blood collection and storage. Updated references and reformatted guideline.

01/01/13

Annual CPT coding update. Revised code descriptor for 38241.

09/15/13

Revision; updated Florida Administrative Rule 59B-12.001 language.

10/15/13

Scheduled review. Revised position statement and updated references.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2013 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. CPT® is a trademark of the American Medical Association.The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Internet Privacy Statement   |   Terms of Use
 

Date Printed: September 23, 2014: 08:19 AM