Hematopoietic Cell Transplant for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma (ARCHIVED)

Policy ID: S-206-016

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This policy has been Archived effective September 05, 2022.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-206-015

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 05, 2022

Applies To: Commercial and Medicaid Expansion

Description

Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are cancers that affect lymphocytes. CLL and SLL are essentially the same disease, with the only difference being the location where the cancer primarily occurs. When most of the cancer cells are located in the bloodstream and the bone marrow, the disease is referred to as CLL, although the lymph nodes and spleen are often involved. When the cancer cells are located mostly in the lymph nodes, the disease is called SLL.

Hematopoietic cell transplantation (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 HCT may be considered medically necessary to treat individuals with markers of poor-risk disease for EITHER of the following conditions:

CLL; or
SLL

Use of a myeloablative or reduced-intensity pre-transplant conditioning regimen should be individualized based on factors that include individual age, the presence of comorbidities, and disease burden.

Allogeneic HCT to treat CLL or SLL 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

38205

38240

S2140

S2142

Autologous HCT to treat CLL or SLL 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

38241

Diagnosis Codes

C91.10

C91.11

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) – 2021

Indications for Allogeneic HCT for CLL/SLL (v.1.2022)

Allogeneic HCT can be considered for CLL/SLL refractory to small-molecule inhibitor therapy in [individuals] without significant comorbidities. HCT-specific comorbidity index (HCT-Cl) could be used for the assessment of comorbidities prior to HCT and to predict the risks of non-relapse mortality and the probabilities of survival after HCT.

For individuals with CLL/SLL with del(17p) or TP53 mutation, a discussion of allogeneic HCT could be considered for [individuals] in remission with or after ibrutinib therapy, if CK (greater than or equal to 3 abnormalities) is present. However, available data suggests that CK (greater than or equal to 5 abnormalities) is associated with inferior overall survival and EFS following allogeneic HCT with reduced-intensity conditioning in [individuals] with high-risk interphase cytogenetics.

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Reformatting.

Internal Medical Policy Committee 11-19-2020 Changed wording around; removed procedure codes 38220; 38221 and 38222

Internal Medical Policy Committee 11-23-2021 Annual Review, no changes in criteria.

Internal Medical Policy Committee 01-20-2022 Revision-updated professional statement

Internal Medical Policy Committee 7-21-2022 Archiving policy Effective September 5, 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.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search

Stay updated on HealthCare News