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).

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.

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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

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

Diagnosis Codes