Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer (ARCHIVED)

Policy ID: S-211-012

Section: Surgery

Effective Date: July 01, 2018

Revised Date: May 14, 2021

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2022

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective May 02, 2022. Click the Archive tab above for more information.

Policy ID: S-211-012

Section: Surgery

Effective Date: July 01, 2018

Revised Date: May 14, 2021

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2022

Archived Date: May 02, 2022

Applies To: Commercial and Medicaid Expansion

Description

Several types of malignancies can arise in the ovary; epithelial carcinoma is the most common. Epithelial ovarian cancer forms in the tissues covering the ovary.

Hematopoietic cell transplantation (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.

Criteria

Autologous and allogeneic hematopoietic cell transplantation are considered experimental/investigational to treat advanced stage epithelial ovarian cancer 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

38240

38241

S2140

S2142

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) - 2020

Current NCCN guidelines (v.1.2020) do not address hematopoietic cell transplantation for epithelial ovarian cancer for individuals either with newly diagnosed or with relapsed or refractory disease.

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Reformatting of policy

Internal Medical Policy Committee 5-19-2020 Updating language, Annual Review

Internal Medical Policy Committee 5-20-2021 Revised Description statement

Internal Medical Policy Committee 3-23-2022 Archiving For services rendered on or after May 02, 2022, refer to Medical Policy S-271, Hematopoietic Cell Transplantation: Experimental/Investigational Services

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.

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