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Allogeneic And Autologous Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia (ALL) in Adults and Children

Section: Surgery
Effective Date: July 01, 2018
Revised Date: September 26, 2019

Description

ALL is a heterogeneous disease with different genetic variations resulting in distinct biologic subtypes. Individuals are stratified to risk-adapted therapy according to certain clinical and genetic risk factors that predict outcome. Therapy may include hematopoietic cell transplantation (HCT).

HCT involves the intravenous (IV) infusion of allogeneic 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.

Allogeneic HCT is stem cells obtained from a donor, i.e., sibling, family member, or non-family member.

Autologous hematopoietic stem cell transplant (HCT) is stem cells obtained from the transplant recipient.

Criteria

Childhood ALL

Autologous or allogeneic (HCT) may be considered medically necessary to treat childhood ALL when at least ONE of the following criteria has been met:

  • In first complete remission and at high risk of relapse; or
  • In second or greater remission or refractory ALL.

Allogeneic HCT may be considered medically necessary for the treatment of relapsing ALL after a prior autologous HCT.

Autologous or allogeneic HCT for any other indication than listed above will be considered not medically necessary.

Procedure Codes

38204 38205 38206 38208 38209 38210 38211
38212 38213 38214 38215 38220 38221 38222
38230 38232 38240 38241 86812 86813 86816
86817 86821 S2140 S2142

Adult ALL

Autologous HCT may be considered medically necessary to treat adult ALL in first complete remission but at high risk of relapse.

Allogeneic (HCT) may be considered medically necessary to treat adult ALL when at least ONE of the following clinical criteria has been met:

  • In first complete remission for any risk level of relapse; or
  • In second or greater remission or with relapsed or refractory ALL; or
  • In relapse after a prior autologous HCT.

Autologous HCT to treat adult ALL in second or greater remission or with refractory disease is considered experimental and investigational (E/I) and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available peer-reviewed literature.

Autologous or allogeneic HCT for any other indication than listed above will be considered not medically necessary.

Procedure Codes

38204 38205 38206 38208 38209 38210 38211
38212 38213 38214 38215 38220 38221 38230
38232 38240 38241 86812 86813 86816 86817
86821 S2140 S2142

Reduced-Intensity Conditioning (RIC)

RIC-allogeneic HCT may be considered medically necessary as a treatment for ALL in patients who are in complete marrow and extramedullary first or second remission, and who, for medical reasons, would be unable to tolerate a standard myeloablative conditioning regimen. Examples of some of those medical reasons are as follows, but are not limited to:

  • Having comorbidities such as: 
    • Liver or kidney dysfunction; or
    • Generalized debilitation; or
    • Prior intensive chemotherapy; or
    • Low Karnofsky Performance Status.

RIC HCT for any indication other than listed above is considered not medically necessary.

Procedure Codes

38220 38221 38230 38240 86812 86813 86816
86817 86821 S2140 S2142

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38222, 38230, 38232, 38240, 38241, 86812, 86813, 86816, 86817, 86821, S2140, S2142

C91.00 C91.01 C91.02

Links

  1. InterQual® Level of Care Criteria 2018. Acute Care Adult. McKesson Health Solutions, LLC.
  2. Dhédin N, Huynh A, Maury S, et al. Role of allogeneic stem cell transplantation in adult patients with Ph-negative acute lymphoblastic leukemia. Blood. 2015; 125(16):2486-2496.
  3. National Comprehensive Cancer Network. NCCN clinical practice guidelines in Oncology V.1.2018. Acute Lymphoblastic Leukemia.
  4. Larson RA. Patient information: Acute lymphoblastic leukemia (ALL) treatment in adults (Beyond the Basics. UpToDate. Last updated May 4, 2016.
  5.  NIH-National Cancer Institute, Childhood Acute Lymphoblastic Leukemia Treatment-Patient Version. 2019.
  6. Horton TM, Steuber CP. Overview of the treatment of acute lymphoblastic leukemia in children and adolescents. UpToDate. Last updated April 5, 2016.
  7. Santoro N, Ruggeri A, Labopin M, et al. Unmanipulated haploidentical stem cell transplantation in adults with acute lymphoblastic leukemia: a study on behalf of the Acute Leukemia Working Party of the EBMT. Journal of Hematology & Oncology [serial online]. 2017; 10(1):113.
  8. Wahid, et al. Comparison of reduced-intensity and myeloablative conditioning regimens for allogeneic hematopoietic stem cell transplantation in patients with acute myeloid leukemia and acute lymphoblastic leukemia: A meta-analysis. Stem Cells and Dev. 2014; 23(21):2535–2552
  9. Ding Z, et al. Outcomes of adults with acute lymphoblastic leukemia after autologous hematopoietic stem cell transplantation and the significance of pretransplantation minimal residual disease: analysis from a single center of China. Chin Med J. 2015; 128(15):2065–2071.
  10. Giebel S, Labopin M, Nagler A, et al. Improving results of allogeneic hematopoietic cell transplantation for adults with acute lymphoblastic leukemia in first complete remission: an analysis from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica [serial online]. 2017; 102(1):139-149.
  11. Rosko A, Wang HL, de Lima M, et al. Reduced intensity conditioned allograft yields favorable survival for older adults with B-cell acute lymphoblastic leukemia. Am J Hematol. 2016; 92(1):42- 49.
  12. Pavlu J, Labopin M, Zoellner AK, et al. Allogeneic hematopoietic cell transplantation for primary refractory acute lymphoblastic leukemia: A report from the Acute Leukemia Working Party of the EBMT. Cancer. Jun 01 2017; 123(11):1965-1970.
  13. NIH-National Cancer Institute, Childhood Acute Lymphoblastic Leukemia Treatment-Health Professional Version. 2019. Accessed February 4, 2019.
  14. NIH-National Cancer Institute, Adult Acute Lymphoblastic Leukemia Treatment-Health Professional Version. 2018. Accessed February 4, 2019.
  15. Majhail NS, Farnia SH, Carpenter PA, et al. Indications for autologous and allogeneic hematopoietic cell transplantation: guidelines from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant. Nov 2015; 21(11):1863-1869.