Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

Policy ID: S-216-013

Section: Surgery

Effective Date: July 01, 2018

Revised Date: July 22, 2020

Revision Effective Date: September 01, 2020

Last Reviewed: July 22, 2020

Description

Embryonal tumors of the central nervous system are cancerous (malignant) tumors that start in the embryonic cells in the brain. Embryonal tumors can occur at any age, but most often occur in babies and young children. Types of tumors include: medulloblastoma, embryonal tumors with multi-layered rosettes, medulloepitheliomas, atypical teratoid/rhaboid tumors, and other nonspecified embryonal tumors.

Ependymoma is a type of tumor that can form in the brain or spinal cord. Ependymoma begins in the ependymal cells in the brain and spinal cord that line the passageways where the cerebrospinal fluid flows.

Hematopoietic cell transplantation (HCT) involves the intravenous (IV) infusion of allogeneic or autologous stem cells to re-establish 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

Embryonal Tumors

Autologous HCT may be considered medically necessary when ONE of the following are met:

As consolidation therapy for previously untreated embryonal tumors of the central nervous system (CNS) that show partial or complete response to induction chemotherapy; or
Stable disease after induction therapy; or
To treat recurrent embryonal tumors of the CNS.

Autologous HCT for any other indication is considered not medically necessary.

Tandem autologous HCT may be considered medically necessary as an adjuvant therapy to treat embryonal tumors of the CNS when ALL of the following criteria are met:

Individual is receiving high dose chemotherapy; and
Individual is status post resection or conventional re-induction chemotherapy.

Tandem autologous HCT for any other indication is considered not medically necessary.

Procedure Codes

38206

38232

38241

S2150

Allogeneic HCT is considered experimental/investigational (E/I) to treat embryonal tumors of the CNSand 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

38230

38240

S2140

S2142

Ependymoma

Autologous, tandem autologous and allogeneic HCT is consideredE/I to treat ependymoma 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

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 38206, 38232, 38241, S2150*

C71.0	C71.1	C71.2	C71.3	C71.4	C71.5	C71.6
C71.7	C71.8

Non-Covered Diagnosis Codes for Procedure Codes: 38205, 38230, 38240, S2140, S2142, S2150*

C71.0	C71.1	C71.2	C71.3	C71.4	C71.5	C71.6
C71.7	C71.8

Non-Covered Diagnosis Codes for Procedure Codes: 38205, 38206, 38230, 38232, 38240, 38241, S2140, S2142

C71.9

* The diagnosis procedure code S2150 may be considered medically necessaryONLYfor autologous hematopoietic stem cell transplantation meeting policy criteria.

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network – 2019

Current National Comprehensive Cancer Network (v.3.2019) guidelines on treating central nervous system tumors make the following recommendations about hematopoietic cell transplant (HCT):

For medulloblastoma and supratentorial primitive neuroectodermal tumor, autologous HCT for localized recurrent disease with maximum safe resection is a category 2A recommendation.

American Society for Blood and Marrow Transplantation – 2015

The American Society for Blood and Marrow Transplantation (2015) published consensus guidelines on the use of HCT to treat specific conditions, in both clinical trial and clinical practice settings. Per this review, clinical evidence is available to support autologous HCT in pediatric individuals (<18 years) with medulloblastoma. Stem cell transplantation is not generally recommended using allogeneic HCT for medulloblastomas. The guidelines did not address HCT in treating ependymomas.

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Reformatting policy. No difference in criteria.

Internal Medical Policy Committee 7-22-2020 Coding Update

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.

Section: Surgery

Effective Date: July 01, 2018

Revised Date: November 12, 2019

Archived Date: August 17, 2020

Description

Allogeneic HCT is stem cells obtained from a donor i.e. sibling, family member, or non-family member.

Autologous hematopoietic stem cell transplant (HCT) is stem cells obtained from the transplant recipient.

Criteria

Autologous HCT may be considered medically necessary when ONE of the following are met:

As consolidation therapy for previously untreated embryonal tumors of the central nervous system (CNS) that show partial or complete response to induction chemotherapy; or
Stable disease after induction therapy; or
To treat recurrent embryonal tumors of the CNS.

Autologous HCT for any other indication is considered not medically necessary.

Tandem autologous HCT may be considered medically necessary as an adjuvant therapy to treat embryonal tumors of the CNS when ALL of the following criteria are met:

Individual is receiving high dose chemotherapy; and
Individual shows no evidence of disease following resection or conventional re-induction chemotherapy.

Tandem autologous HCT for any other indication is considered not medically necessary.

Procedure Codes

38206

38220

38221

38222

38232

38241

S2150

Procedure Codes

38205	38220	38221	38222	38230	38240	S2140
S2142

Procedure Codes

38205	38206	38220	38221	38222	38230	38232
38240	38241	S2140	S2142

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 38206, 38220, 38221, 38232, 38241, S2150*

C71.0	C71.1	C71.2	C71.3	C71.4	C71.5	C71.6
C71.7	C71.8

Non-Covered Diagnosis Codes for Procedure Codes: 38205, 38230, 38240, S2140, S2142, S2150*

C71.0	C71.1	C71.2	C71.3	C71.4	C71.5	C71.6
C71.7	C71.8

Non-Covered Diagnosis Codes for Procedure Codes: 38205, 38206, 38220, 38221, 38230, 38232, 38240, 38241, S2140, S2142

C71.9

* The diagnosis procedure code S2150 may be considered medically necessary ONLY for autologous hematopoietic stem cell transplantation meeting policy criteria.

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