Criteria
Autologous HCT may be considered medically necessary in individuals with primary refractory or relapsed Hodgkin lymphoma (HL).
Tandem autologous HCT may be considered medically necessary:
- In individuals with primary refractory HL; or
- In individuals with relapsed disease with poor risk features who do not attain a complete remission to cytoreductive chemotherapy prior to transplantation.
Second autologous cell transplantation for relapsed lymphoma after a prior autologous HCT is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Allogeneic HCT, using either myeloablative or reduced-intensity conditioning regimens, may be considered medically necessary in individuals with primary refractory or relapsed HL.
Other uses of HCT in individuals with HL are considered experimental/investigational including, but not limited to, initial therapy for newly diagnosed disease to consolidate a first complete remission 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
38204
|
38205
|
38206
|
38230
|
38232
|
38240
|
38241
|
S2140
|
S2142
|
S2150
|