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Hematopoietic Cell Transplantation for Hodgkin Lymphoma

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 18, 2019
Last Reviewed: November 14, 2019

Description

Hematopoietic cell transplantation (HCT) refers to a procedure in which hematopoietic cells are infused to restore bone marrow function in cancer patients who receive bone-marrow-toxic doses of cytotoxic drugs with or without whole body radiation therapy. Hematopoietic cells may be obtained from the transplant recipient (autologous HCT) or from a donor (allogeneic HCT).

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. Available scientific evidence does not permit conclusions concerning the effect of this intervention on health outcomes.

Procedure Codes

38204 38206 38220 38221 38222 38232 38241
S2150

Allogeneic HCT, using either myeloablative or reduced-intensity conditioning regimens, may be considered medically necessary in individuals with primary refractory or relapsed HL.

Procedure Codes

38204 38205 38220 38221 38222 38230 38240
S2140 S2142 S2150

HCT in individuals with HL are considered experimental/investigational and, therefore, non-covered for all other indications including, but not limited to, initial therapy for newly diagnosed disease to consolidate a first complete remission. Available scientific evidence does not permit conclusions concerning the effect of this intervention on health outcomes.

Procedure Codes

38204 38205 38206 38220 38221 38222 38230
38232 38240 38241 S2140 S2142 S2150 38240

Diagnosis Codes

C81.00 C81.01 C81.02 C81.03 C81.04 C81.05 C81.06
C81.07 C81.08 C81.09 C81.10 C81.11 C81.12 C81.13
C81.14 C81.15 C81.16 C81.17 C81.18 C81.19 C81.20
C81.21 C81.22 C81.23 C81.24 C81.25 C81.26 C81.27
C81.28 C81.29 C81.30 C81.31 C81.32 C81.33 C81.34
C81.35 C81.36 C81.37 C81.38 C81.39 C81.40 C81.41
C81.42 C81.43 C81.44 C81.45 C81.46 C81.47 C81.48
C81.49 C81.70 C81.71 C81.72 C81.73 C81.74 C81.75
C81.76 C81.77 C81.78 C81.79 C81.90 C81.91 C81.92
C81.93 C81.94 C81.95 C81.96 C81.97 C81.98 C81.99

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