Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (ARCHIVED)

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Policy ID: S-209-014

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This policy has been Archived effective September 05, 2022.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-209-013

Section: Surgery

Effective Date: July 01, 2018

Revised Date: December 15, 2021

Revision Effective Date: March 07, 2022

Last Reviewed: January 20, 2022

Archived Date: September 04, 2022

Applies To: Commercial and Medicaid Expansion

Description

Myelodysplastic syndromes are a group of disorders caused by blood cells that are poorly formed or don't work properly.

Myeloproliferative neoplasms are a group of diseases in which the bone marrow makes too many red blood cells, white blood cells, or platelets.

Allogeneic hematopoietic cell transplantation (allo-HCT) involves the intravenous (IV) infusion of allogeneic (donor) 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

Myeloablative allo-HCT may be considered medically necessary as a treatment of EITHER of the following conditions:

Myelodysplastic syndromes; or
Myeloproliferative neoplasms.

Reduced-intensity conditioning allo-HCT may be considered medically necessary as a risk-adapted treatment in individuals, who for medical reasons would be unable to tolerate a myeloablative conditioning regimen as a treatment of EITHER of the following conditions:

Myelodysplastic syndromes; or
Myeloproliferative neoplasms.

Myeloablative allo-HCT or reduced-intensity conditioning allo-HCT for myelodysplastic syndromes and myeloproliferative neoplasms not meeting the criteria as indicated in this policy is considered experimental/investigational (E/I) 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

38205

38230

38240

S2140

S2142

S2150

Diagnosis Codes

C88.8

C94.40

C94.41

C94.42

C94.6

D46.0

D46.1

D46.20

D46.21

D46.22

D46.4

D46.9

D46.A

D46.B

D46.C

D46.Z

D47.1

D47.Z9

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN)-2021

Myelodysplastic Syndromes – v.1.2.2022 – 2021

Allogeneic HCT from an HLA-matched sibling, matched unrelated, or alternative donor is a preferred approach for treating select individuals with MDS, particularly those with high-risk disease. This includes both standard and RIC strategies.

Myeloproliferative Neoplasms – v.2.2021 - 2021

Allogeneic HCT is the only potentially curative treatment option resulting in long-term remissions for individuals with MF. However, the use of myeloablative conditioning is associated with higher rates of non-relapse mortality (NRM).

ND Committee Review

Internal Medical Policy Committee 11-14-2019 New Policy

Internal Medical Policy Committee 11-19-2020 Annual review

Internal Medical Policy Committee 11-23-2021 Annual review

Internal Medical Policy Committee 01-20-2022 Revision-updated descriptions and Professional statements

Internal Medical Policy Committee 07-21-2022 Archiving policy - Effective September 05, 2022
• Please refer to policy S-272, Hematopoietic Cell Transplantation: Blood Cancers after this effective date.

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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