Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia (ARCHIVED)

Policy ID: S-218-014

Section: Surgery

Effective Date: July 01, 2018

Revised Date: June 02, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: July 21, 2022

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective September 05, 2022. Please refer to S-272, Hematopoietic Cell Transplantation: Blood Cancers.

Click the Archive tab above for more information.

Policy ID: S-218-013

Section: Surgery

Effective Date: July 01, 2018

Revised Date: July 14, 2021

Revision Effective Date: September 06, 2021

Last Reviewed: July 22, 2021

Archived Date: September 04, 2022

Applies To: Commercial and Medicaid Expansion

Description

Chronic myeloid leukemia (CML) is a hematopoietic stem cell disorder characterized by the presence of a chromosomal abnormality called the Philadelphia chromosome, which results from a reciprocal translocation between the long arms of chromosomes 9 and 22. CML most often presents in a chronic phase from which it progresses to an accelerated and then a blast phase. Allogeneic hematopoietic cell transplantation (HCT) is a treatment option for CML.

HCT involves the intravenous (IV) infusion of allogeneic (donor) or autologous stem cells to reestablish hematopoietic function in individuals whose bone marrow or immune system is damaged or defective. They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates

Criteria

Allogeneic hematopoietic cell transplantation (HCT) using a myeloablative conditioning regimen may be considered medically necessary as a treatment of CML.

Allogeneic HCT, using either a myeloablative or a reduced-intensity conditioning (RIC) regimen for CML, may be considered medically necessary for individuals who qualify based on clinical criteria:

Clinical criteria for myeloablative or RIC regimen may include those individuals:
- Whose age (typically greater than 60 years) precludes use of a standard myeloablative conditioning regimen; or
- Whose comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy, low Karnofsky Performance Status) preclude use of a standard myeloablative conditioning regimen.

Allogeneic HCT not meeting the criteria as indicated in this policy is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

38204

38205

38208

38209

38210

38211

38212

38213

38214

38215

38230

38240

S2140

S2142

Autologous HCT for CML is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

38206

38232

38241

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 38204, 38205, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38222, 38230, 38240, S2140 and S2142

C92.10

C92.12

C92.20

C92.22

Non-covered Diagnosis Codes for Procedure codes 38206, 38232, and 38241

C92.10

C92.12

C92.20

C92.22

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN)- 2021

Current NCCN guidelines (v.3.2021) recommend allogeneic hematopoietic cell transplantation (allo-HCT) as an alternative treatment only for high-risk settings or in individuals with advanced phase chronic myeloid leukemia (CML). Relevant recommendations are:

"Allogeneic HCT is no longer recommended as a first-line treatment option for CP [chronic phase] CML."
"Allogeneic HCT is an appropriate treatment option for the very rare individuals presenting with BP [blast phase]-CML at diagnosis, individuals with disease that is resistant to TKIs, individuals with progression to AP [accelerated phase]-CML or BP-CML while on TKI therapy, and for the rare individuals intolerant to all TKIs"
Evaluation for allogeneic HCT...is recommended for all individuals with AP-CML or BP-CML"

The Network guidelines also state: "Non-myeloablative allogeneic HCT is a well-tolerated treatment option for individuals with a matched donor and the selection of individuals is based on their age and the presence of comorbidities."

Autologous HCT for CML is not addressed in these guidelines.

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Language update

Internal Medical Policy Committee 5-19-2020 Annual Review

Internal Medical Policy Committee 5-20-2021 Annual Review-no changes to criteria

Internal Medical Policy Committee 7-22-2021 Revision - language updates

Internal Medical Policy Committee 7-21-2022 Archiving policy Effective September 05, 2022

Please refer to S-272, Hematopoietic Cell Transplantation: Blood Cancers.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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