All Policies and Precertification
Chronic myeloid leukemia (CML) is a hematopoietic stem cell disorder characterized by the presence of a chromosomal abnormality called the Philadelphia chromosome, which results from a reciprocal translocation between the long arms of chromosomes 9 and 22. CML most often presents in a chronic phase from which it progresses to an accelerated and then a blast phase. Allogeneic hematopoietic cell transplantation (allo-HCT) is a treatment option for CML.
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
Allogeneic hematopoietic cell transplantation (HCT) using a myeloablative conditioning regimen may be considered medically necessary as a treatment of CML.
Allogeneic HCT using a reduced-intensity conditioning (RIC) regimen may be considered medically necessary as a treatment of CML in individuals who meet clinical criteria for an allogeneic HCT but who are not considered candidates for a myeloablative conditioning allogeneic HCT.
Autologous HCT is considered experimental/investigational and, therefore, non-coveredbecause the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Covered Diagnosis Codes for Procedure Codes 38204, 38205, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38222, 38230, 38240, S2140 and S2142
Non-covered Diagnosis Codes for Procedure codes 38206, 38232, and 38241
National Comprehensive Cancer Network - 2020
Current National Comprehensive Cancer Network guidelines (v.2.2020) recommend allogeneic hematopoietic cell transplantation (allo-HCT) as an alternative treatment only for high-risk settings or in individuals with advanced phase chronic myeloid leukemia (CML). Relevant recommendations are:
The Network guidelines also state: "Non-myeloablative allogeneic HCT is a well-tolerated treatment option for individuals with a matched donor and the selection of individuals is based on their age and the presence of comorbidities."
Autologous HCT for CMLis not addressedin these guidelines.
Internal Medical Policy Committee 11-14-2019 Language update
Internal Medical Policy Committee 5-19-2020 Annual Review
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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