Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (ARCHIVED)

Policy ID: S-212-012

Section: Surgery

Effective Date: July 01, 2018

Revised Date: October 28, 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This policy has been Archived effective May 02, 2022.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-212-012

Section: Surgery

Effective Date: July 01, 2018

Revised Date: October 28, 2021

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2022

Archived Date: May 02, 2022

Applies To: Commercial and Medicaid Expansion

Description

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.

HCT is an established treatment for certain hematologic malignancies and has been investigated for a variety of adult solid tumors.

Criteria

Autologous or allogeneic hematopoietic cell transplant is considered experimental/investigational for the following malignancies in adults and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

Breast Cancer; or
Cancer of the bile duct; or
Cancer of the fallopian tubes; or
Cervical cancer; or
Colon cancer; or
Esophageal cancer; or
Gall bladder cancer; or
Lung cancer, any histology; or
Malignant melanoma; or
Nasopharyngeal cancer; or
Neuroendocrine tumors; or
Pancreatic cancer; or
Paranasal sinus cancer; or
Prostate cancer; or
Rectal cancer; or
Renal cell cancer; or
Soft tissue sarcomas; or
Stomach cancer; or
Thyroid tumors; or
Tumors of the thymus; or
Tumors of unknown primary origin; or
Uterine cancer

Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.

Procedure Codes

38205

38206

38240

38241

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network - 2021

Current National Comprehensive Cancer Network guidelines on the tumors addressed in this evidence review do not discuss hematopoietic cell transplantation (HCT) as a treatment option.

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Coding update

Internal Medical Policy Committee 9-21-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 updated criteria to include breast cancer

Internal Medical Policy 3-23-2022 Archiving as of 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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