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.

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

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

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

Diagnosis Codes

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

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

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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