Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas (ARCHIVED)

Policy ID: S-208-015

Section: Surgery

Effective Date: January 01, 2019

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This policy has been Archived effective September 05, 2022.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-208-014

Section: Surgery

Effective Date: January 01, 2019

Revised Date: October 13, 2021

Revision Effective Date: January 03, 2021

Last Reviewed: November 23, 2021

Archived Date: September 04, 2022

Applies To: Commercial and Medicaid Expansion

Description

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.

Non-Hodgkin's lymphoma (NHL) is an extremely heterogeneous group of lymphoid malignancies whose diversity relates to their epidemiology, natural history, morphology, immunology, cytogenetics and response to standard doses of chemotherapy.

Criteria

Non-Hodgkin Lymphoma (NHL) B-Cell Subtypes

Aggressive NHL B-cell Subtype

Allogeneic HCT using a myeloablative conditioning regimen or autologous HCT may be considered medically necessary to treat individuals with aggressive NHL B-cell subtypes (EXCEPT mantle cell lymphoma) for ANY of the following:

As salvage therapy for individuals who do not achieve CR after first-line treatment (induction) with a full course of standard-dose chemotherapy; or
To achieve or consolidate CR for individuals in a first or subsequent chemo-sensitive relapse, whether or not their lymphoma has undergone transformation to a higher grade.
To consolidate a first CR in individuals with diffuse large B-cell lymphoma, with an age-adjusted International Prognostic Index score that predicts a high- or high-intermediate risk of relapse.

Indolent NHL B-cell Subtype

Allogeneic HCT using a myeloablative conditioning regimen or autologous HCT maybe considered medically necessary to treat individuals with indolent NHL B-cell subtypes for ANY of the following:

As salvage therapy for individuals who do not achieve CR after first-line treatment (induction) with a full course of standard-dose chemotherapy; or
To achieve or consolidate CR for individuals in a first or subsequent chemo-sensitive relapse, whether or not their lymphoma has undergone transformation to a higher grade.

Mantle Cell Lymphoma

Autologous HCT may be considered medically necessary to consolidate a first remission of mantle cell lymphoma.
Allogeneic HCT is considered experimental/investigational to consolidate a first remission of mantle cell lymphoma and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Salvage Therapy for Mantle Cell Lymphoma

Allogeneic HCT, myeloablative or reduced-intensity conditioning, used as salvage therapy for mantle cell lymphoma may be considered medically necessary.
Autologous HCT used as salvage therapy for mantle cell lymphoma 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.

Reduced-intensity conditioning (RIC) allogeneic HCT to treat individuals with NHL may be considered medically necessary for those individuals who meet the above criteria for an allogeneic HCT but who do not qualify for a myeloablative allogeneic HCT.

Autologous HCT or allogeneic HCT 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 for ANY of the following treatments:

As initial therapy for any NHL; or
To consolidate a first CR for individuals with diffuse large B-cell lymphoma and an International Prognostic Index score that predicts a low- or low-intermediate risk of relapse; or
To consolidate a first CR for individuals with indolent NHL B-cell subtypes

Tandem HCT to treat individuals with any stage, grade, or subtype of NHL 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.

T-cell Lymphoma

HCT may be considered medically necessary for individuals with mature T-cell or natural killer cell (peripheral T-cell) neoplasms as follows:

Autologous HCT may be considered medically necessary to consolidate a first complete remission in high-risk peripheral T-cell lymphoma.

Autologous or allogeneic HCT (myeloablative or reduced-intensity conditioning) may be considered medically necessary as salvage therapy.

Autologous or allogeneic HCT for treatment of T-cell lymphoma 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.

Allogeneic HCT to consolidate a first remission 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

38206

38230

38232

38240

38241

S2140

S2142

S2150

Table: Updated World Health Organization (WHO) Classification 2016

Mature B-cell neoplasms

Chronic lymphocytic leukemia/small lymphocytic lymphoma

Monoclonal B-cell lymphocytosis*

B-cell prolymphocytic leukemia

Splenic marginal zone lymphoma

Hairy cell leukemia

Splenic B-cell lymphoma/leukemia, unclassifiable

- Splenic diffuse red pulp small B-cell lymphoma
- Hairy cell leukemia-variant

Lymphoplasmacytic lymphoma

- Waldenström macroglobulinemia

Monoclonal gammopathy of undetermined significance (MGUS), IgM*

μ heavy-chain disease

γ heavy-chain disease

α heavy-chain disease

Monoclonal gammopathy of undetermined significance (MGUS), IgG/A*

Plasma cell myeloma

Solitary plasmacytoma of bone

Extraosseous plasmacytoma

Monoclonal immunoglobulin deposition diseases*

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

Nodal marginal zone lymphoma

- Pediatric nodal marginal zone lymphoma

Follicular lymphoma

- In situ follicular neoplasia*
- Duodenal-type follicular lymphoma*

Pediatric-type follicular lymphoma*

Large B-cell lymphoma with IRF4 rearrangement*

Primary cutaneous follicle center lymphoma

Mantle cell lymphoma

- In situ mantle cell neoplasia*

Diffuse large B-cell lymphoma (DLBCL), NOS

- Germinal center B-cell type*
- Activated B-cell type*

T-cell/histiocyte-rich large B-cell lymphoma

Primary DLBCL of the central nervous system (CNS)

Primary cutaneous DLBCL, leg type

EBV+ DLBCL, NOS*

EBV+ mucocutaneous ulcer*

DLBCL associated with chronic inflammation

Lymphomatoid granulomatosis

Primary mediastinal (thymic) large B-cell lymphoma

Intravascular large B-cell lymphoma

ALK+ large B-cell lymphoma

Plasmablastic lymphoma

Primary effusion lymphoma

HHV8+ DLBCL, NOS*

Burkitt lymphoma

Burkitt-like lymphoma with 11q aberration*

High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements*

High-grade B-cell lymphoma, NOS*

B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma

Mature T and NK neoplasms

T-cell prolymphocytic leukemia

T-cell large granular lymphocytic leukemia

Chronic lymphoproliferative disorder of NK cells

Aggressive NK-cell leukemia

Systemic EBV+ T-cell lymphoma of childhood*

Hydroa vacciniforme–like lymphoproliferative disorder*

Adult T-cell leukemia/lymphoma

Extranodal NK-/T-cell lymphoma, nasal type

Enteropathy-associated T-cell lymphoma

Monomorphic epitheliotropic intestinal T-cell lymphoma*

Indolent T-cell lymphoproliferative disorder of the GI tract*

Hepatosplenic T-cell lymphoma

Subcutaneous panniculitis-like T-cell lymphoma

Mycosis fungoides

Sézary syndrome

Primary cutaneous CD30+ T-cell lymphoproliferative disorders

- Lymphomatoid papulosis
- Primary cutaneous anaplastic large cell lymphoma

Primary cutaneous γδ T-cell lymphoma

Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma

Primary cutaneous acral CD8+ T-cell lymphoma*

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder*

Peripheral T-cell lymphoma, NOS

Angioimmunoblastic T-cell lymphoma

Follicular T-cell lymphoma*

Nodal peripheral T-cell lymphoma with TFH phenotype*

Anaplastic large-cell lymphoma, ALK+

Anaplastic large-cell lymphoma, ALK−*

Breast implant–associated anaplastic large-cell lymphoma*

Provisional entities are listed in italics.

*Changes from the 2008 classification.

Diagnosis Codes

C82.00

C82.01

C82.02

C82.03

C82.04

C82.05

C82.06

C82.07

C82.08

C82.09

C82.10

C82.11

C82.12

C82.13

C82.14

C82.15

C82.16

C82.17

C82.18

C82.19

C82.20

C82.21

C82.22

C82.23

C82.24

C82.25

C82.26

C82.27

C82.28

C82.29

C82.30

C82.31

C82.32

C82.33

C82.34

C82.35

C82.36

C82.37

C82.38

C82.39

C82.40

C82.41

C82.42

C82.43

C82.44

C82.45

C82.46

C82.47

C82.48

C82.49

C82.50

C82.51

C82.52

C82.53

C82.54

C82.55

C82.56

C82.57

C82.58

C82.59

C82.60

C82.61

C82.62

C82.63

C82.64

C82.65

C82.66

C82.67

C82.68

C82.69

C82.80

C82.81

C82.82

C82.83

C82.84

C82.85

C82.86

C82.87

C82.88

C82.89

C82.90

C82.91

C82.92

C82.93

C82.94

C82.95

C82.96

C82.97

C82.98

C82.99

C83.00

C83.01

C83.02

C83.03

C83.04

C83.05

C83.06

C83.07

C83.08

C83.09

C83.10

C83.11

C83.12

C83.13

C83.14

C83.15

C83.16

C83.17

C83.18

C83.19

C83.30

C83.31

C83.32

C83.33

C83.34

C83.35

C83.36

C83.37

C83.38

C83.39

C83.50

C83.51

C83.52

C83.53

C83.54

C83.55

C83.56

C83.57

C83.58

C83.59

C83.70

C83.71

C83.72

C83.73

C83.74

C83.75

C83.76

C83.77

C83.78

C83.79

C83.80

C83.81

C83.82

C83.83

C83.84

C83.85

C83.86

C83.87

C83.88

C83.89

C83.90

C83.91

C83.92

C83.93

C83.94

C83.95

C83.96

C83.97

C83.98

C83.99

C84.40

C84.41

C84.42

C84.43

C84.44

C84.45

C84.46

C84.47

C84.48

C84.49

C84.60

C84.61

C84.62

C84.63

C84.64

C84.65

C84.66

C84.67

C84.68

C84.69

C84.70

C84.71

C84.72

C84.73

C84.74

C84.75

C84.76

C84.77

C84.78

C84.79

C84.90

C84.91

C84.92

C84.93

C84.94

C84.95

C84.96

C84.97

C84.98

C84.99

C84.A0

C84.A1

C84.A2

C84.A3

C84.A4

C84.A5

C84.A6

C84.A7

C84.A8

C84.A9

C84.Z0

C84.Z1

C84.Z2

C84.Z3

C84.Z4

C84.Z5

C84.Z6

C84.Z7

C84.Z8

C84.Z9

C85.10

C85.11

C85.12

C85.13

C85.14

C85.15

C85.16

C85.17

C85.18

C85.19

C85.20

C85.21

C85.22

C85.23

C85.24

C85.25

C85.26

C85.27

C85.28

C85.29

C85.80

C85.81

C85.82

C85.83

C85.84

C85.85

C85.86

C85.87

C85.88

C85.89

C85.90

C85.91

C85.92

C85.93

C85.94

C85.95

C85.96

C85.97

C85.98

C85.99

C86.0

C86.1

C86.2

C86.3

C86.4

C86.5

C86.6

C88.4

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network – 2020

Current National Comprehensive Cancer Network guidelines on B-cell lymphomas (v.4.2021) include the following recommendations:

For follicular lymphoma, marginal zone lymphomas, and mantle cell lymphoma, recommend allogeneic HCT as second-line consolidation therapy.
For DLBCL, “[a]allogenic HCT should be considered in selected individuals with mobilization failures and persistent bone marrow involvement or lack of adequate response to second-line therapy, though individuals should be in CR or near CR at the time of transplant.”
For Burkitt lymphoma, allogeneic HCT is an option for selected individuals to achieve a complete or partial response to second-line therapy.

National Comprehensive Cancer Network guidelines on T-cell lymphomas (v.1.2021) include the following recommendations:

“Second-line systematic therapy followed by consolidation with HDT [high-dose therapy]/ASCR [autologous stem cell rescue] or allogeneic HCT for those with a CR [complete response] or PR [partial response] is recommended for individuals who are candidates for transplant.”
“Allogeneic HCT should be considered for individuals with acute or lymphoma [ATLL] subtype, if donor is available.”
“In individuals with acute or lymphoma subtypes who achieve a response to second-therapy, allogeneic HCT should be considered if a donor is available.”
“In individuals [with T-PLL] who achieve a CR or PR following initial therapy, consolidation with allogeneic HCT should be considered. Autologous HCT may be considered, if a donor is not available and if the individual is not physically fit enough to undergo allogeneic HCT.”

ND Committee Review

Internal Medical Review Committee 11-14-2019 Reformatting to HMK policy, Subtle difference in Criteria (Circulation Update as of 11/4/19)

Internal Medical Review Committee 11-19-2020 Removed procedure codes 38220; 38221; and 38222. Changed the wording and rearranged the indication sections

Internal Medical Review Committee 11-23-2021 updated to clarifying language; title change

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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