Hematopoietic Cell Transplantation (HCT) for Autoimmune Diseases

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 14, 2019

Description

Autoimmune diseases arise from an abnormal immune response of the body against substances and tissues normally present in the body.

HCT is the transplantation of multipotent hematopoietic stem cells; cells can be autologous (the individual's own stem cells are used) or allogeneic (the stem cells come from a donor).

Criteria

Autologous HCT may be considered medically necessary as a treatment of systemic sclerosis/scleroderma when ALL of the following criteria are met:

  • The individual is less than 60 years of age; and
  • Duration of the condition is NOT greater than five (5) years; and
  • Modified Rodnan Scale Scores is greater than or equal to 15; and
  • History of less than six (6) months treatment with cyclophosphamide; and
  • No active gastric antral vascular ectasia.

Autologous HCT for all other autoimmune diseases is considered experimental/investigation and therefore non-covered due to lack of supporting published peer reviewed literature.

Individuals with systemic sclerosis/scleroderma AND internal organ involvement indicated by the following should not be considered for autologous HCT:

  • Cardiac; 
    • Left ventricular ejection fraction less than 50%; or
    • Tricuspid annular plane systolic excursion less than 1.8 cm; or
    • Pulmonary artery systolic pressure greater than 40 mm Hg; or
    • Mean pulmonary artery pressure greater than 25 mm Hg; or
  • Pulmonary; 
    • Diffusing capacity of carbon monoxide (DLCo) less than 40% of predicted value; or
    • Forced vital capacity (FVC) less than 45% of predicted value; or
  • Renal: creatinine clearance less than 40 ml/minute.

Autologous HCT performed in individuals with internal organ involvement, as defined above, is considered not medically necessary.

Procedure Codes

S2150 38206 38220 38221 38222 38232 38241

Allogeneic HCT is considered experimental/investigational and therefore non-covered as a treatment of all autoimmune diseases due to lack of supporting published peer reviewed literature.

Procedure Codes

38205 38220 38221 38222 38230 38240 S2140
S2142 S2150

Diagnosis Codes

M34.0 M34.1 M34.2 M34.81 M34.82 M34.83 M34.89
M34.9

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