Criteria
Donor Leukocyte Infusion
Donor Lymphocyte Infusion may be considered medically necessary for adults and children following allogeneic-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 an individual from mixed to full donor chimerism with ANY of the following conditions:
- Individuals with acute myeloid leukemia (AML); or
- Individuals with chronic myeloid leukemia (CML); or
- Individuals with Hodgkin's disease (HD); or
- Individuals with acute lymphocytic leukemia (ALL); or
- Individuals with multiple myeloma (MM).
DLI is considered experimental/investigational following allogeneic HCT that was originally considered investigational for the treatment of a hematologic malignancy and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
DLI is considered experimental/investigational as a treatment of non-hematologic malignancies following a prior allogeneic HCT and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Other applications of DLI are considered experimental/investigational, including, but not limited to, its use in individuals with myelodysplastic syndromes, non-Hodgkin's lymphoma, and autism spectrum disorder and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Genetic Modification of Donor Leukocytes
Genetic or other modification of donor leukocytes 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
