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Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 12, 2019

Description

Hematopoietic Cell Transplantation (HCT)

HCT refers to a procedure in which hematopoietic stem cells are infused to restore bone marrow function in cancer individuals who receive bone-marrow-toxic doses of cytotoxic drugs with or without whole-body radiation therapy. Hematopoietic cells may be obtained from the transplant recipient (autologous HCT) or from a donor (allogeneic HCT).

Criteria

Allogeneic (HCT) using a myeloablative conditioning regimen may be considered medically necessary to treat ANY of the following conditions:

  • Poor- to intermediate-risk acute myeloid leukemia (AML) in remission (see table attachment for information on risk stratification); or
  • AML that is refractory to, or relapses following, standard induction chemotherapy; or
  • AML in individuals who have relapsed following a prior autologous HCT and are medically able to tolerate the procedure.

Allogeneic HCT using a reduced-intensity conditioning regimen may be considered medically necessary as a treatment of AML in individuals who are in complete marrow and extramedullary remission, and who for medical reasons would be unable to tolerate a myeloablative conditioning regimen.

The use of Allogeneic HCT for all other indications is considered not medically necessary.

 

Procedure Codes

38205 38220 38221 38222 38230 38240 38242
S2140 S2142 S2150

Autologous HCT may be considered medically necessary to treat AML in first or second remission or relapsed AML if responsive to intensified induction chemotherapy.

The use of autologous HCT for all other indications is considered not medically necessary.

Procedure Codes

38206 38220 38221 38222 38232 38241 S2150

Diagnosis Codes

C92.00 C92.01 C92.02 C92.40 C92.41 C92.42 C92.50
C92.51 C92.52 C92.60 C92.61 C92.62 C92.A0 C92.A1
C92.A2 C93.00 C93.01 C93.02 C94.00 C94.01 C94.02
C94.20 C94.21 C94.22

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