Donor Leukocyte Infusion for Hematologic Malignancies that Relapse After Allogeneic Cell Transplant

Effective Date: December 01, 2019
Revised Date: October 25, 2019
Last Reviewed: March 15, 2019

Description

Donor Lymphocyte Infusion (DLI), also called Donor Leukocyte or Buffy-Coat Infusion, is a type of therapy in which T lymphocytes from the blood of a donor are given to a patient who has already received a hematopoietic cell transplant (HCT) from the same donor. The DLI therapeutic effect results from a graft-versus-leukemic or graft-versus-tumor effect due to recognition of certain antigens on the cancer cells by the donor lymphocytes and the resultant elimination of the tumor cells.

Criteria

Donor Leukocyte Infusion

Donor Lymphocyte Infusion may be considered medically necessary for adults and children following allogeneic-hematopoietic cell transplantation (HCT) that was originally considered medically necessary for the treatment of a hematologic malignancy that has relapsed, or does not respond, to prevent relapse in the setting of a high risk of relapse, or to convert a patient from mixed to full donor chimerism with ANY ONE of the following conditions:

  • Individuals with acute myeloid leukemia; or
  • Individuals with chronic myeloid leukemia; or
  • Individuals with Hodgkin’s disease; or
  • Individuals with acute lymphocytic leukemia; or
  • Individuals with multiple myeloma.

Donor Lymphocyte Infusion is considered experimental/investigational following allogeneic hematopoietic stem transplantation (HCT) that was originally considered investigational for the treatment of a hematologic malignancy.

Donor Lymphocyte Infusion is considered experimental/investigational as a treatment of non-hematologic malignancies following a prior allogeneic HCT.

Other applications of donor infusions are considered experimental/investigational, including, but not limited to, its use in patients with myelodysplastic syndromes, non-Hodgkin’s lymphoma, and autism spectrum disorder. In contrast to the experience in patients with CML, there is insufficient scientific evidence to validate the use of donor leukocyte infusions for other applications.

Charges for the leukapheresis procedure for the donor are eligible for payment when the donor leukocyte infusion is covered. All other applications are considered experimental/investigational. Payment for eligible donor leukapheresis procedures may be equated to therapeutic apheresis for white blood cells.

Genetic Modification of Donor Leukocytes
Genetic modification of donor leukocytes is considered experimental/investigational. There is insufficient scientific data to permit conclusions regarding the use of genetic modification of donor leukocytes as an adjunct to donor leukocyte infusion.

Procedure Codes

3651138242

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 38242

C81.00C81.01C81.02C81.03C81.04C81.05C81.06
C81.07C81.08C81.09C81.10C81.11C81.12C81.13
C81.14C81.15C81.16C81.17C81.18C81.19C81.20
C81.21C81.22C81.23C81.24C81.25C81.26C81.27
C81.28C81.29C81.30C81.31C81.32C81.33C81.34
C81.35C81.36C81.37C81.38C81.39C81.40C81.41
C81.42C81.43C81.44C81.45C81.46C81.47C81.48
C81.49C81.70C81.71C81.72C81.73C81.74C81.75
C81.76C81.77C81.78C81.79C81.90C81.91C81.92
C81.93C81.94C81.95C81.96C81.97C81.98C81.99
C90.00C90.01C90.02C91.00C91.01C91.02C91.10
C91.11C91.12C91.30C91.31C91.32C91.50C91.51
C91.52C91.60C91.61C91.62C91.90C91.91C91.92
C91.A0C91.A1C91.A2C91.Z0C91.Z1C91.Z2C92.00
C92.01C92.02C92.10C92.11C92.12C92.20C92.21
C92.22C92.30C92.31C92.32C92.40C92.41C92.42
C92.50C92.51C92.52C92.60C92.61C92.62C92.90
C92.91C92.92C92.A0C92.A1C92.A2C92.Z0C92.Z1
C92.Z2

Non-Covered Diagnosis Codes for Procedure Code 38242

F84.0F84.3F84.5F84.8F84.9

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