Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Section: Surgery
Effective Date: January 01, 2020
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

Hematopoietic stem-cell transplantation (HSCT) refers to a procedure in which hematopoietic stem cells are infused to restore bone marrow function in individuals with cancer who receive bone-marrow-toxic doses of cytotoxic drugs, with or without whole-body radiation therapy. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HSCT) or from a donor (allogeneic HSCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates. Although cord blood is an allogeneic source, the stem cells in it are antigenically “naïve” and thus are associated with a lower incidence of rejection or graft-versus-host disease (GVHD).

For the purposes of this policy, the term “reduced-intensity conditioning” will refer to all conditioning regimens intended to be non-myeloablative, as opposed to fully myeloablative (traditional) regimens.

Criteria

  • For individuals with non-Hodgkin lymphoma (NHL) B-cell subtypes considered aggressive (except mantle cell lymphoma), either allogeneic HSCT using a myeloablative conditioning regimen or autologous HSCT may be considered medically necessary for either of the following:
    • As salvage therapy for individuals who do not achieve a complete remission (CR) after first-line treatment (induction) with a full course of standard-dose chemotherapy; or
    • To achieve or consolidate a CR for those in a chemo-sensitive first or subsequent relapse.
  • For individuals with mantle cell lymphoma:
  • Autologous HSCT may be considered medically necessary to consolidate a first remission.
  • Allogeneic HSCT, myeloablative or reduced-intensity conditioning, may be considered medically necessary as salvage therapy.
  • Autologous HSCT is considered experimental/investigational and therefore, non-covered, as salvage therapy. Scientific evidence does not support this treatment.
  • Allogeneic HSCT is considered experimental/investigational and therefore, non-covered, to consolidate a first remission. Scientific evidence does not support this treatment.
  • For individuals with NHL B-cell subtypes considered indolent, either allogeneic HSCT using a myeloablative conditioning regimen or autologous HSCT may be considered medically necessary for the following:
  • As salvage therapy for individuals who do not achieve CR after first-line treatment (induction) with a full course of standard-dose chemotherapy; or
  • To achieve or consolidate CR for those in a first or subsequent chemosensitive relapse, whether or not their lymphoma has undergone transformation to a higher grade.
  • Reduced-intensity conditioning (RIC) allogeneic HSCT may be considered medically necessary as a treatment of NHL in individuals who meet criteria above for an allogeneic HSCT but who do not qualify for a myeloablative allogeneic HSCT.
  • Either autologous HSCT or allogeneic HSCT is considered experimental/investigational and therefore, non-covered, as scientific evidence does not support these treatments:
  • As initial therapy (i.e., without a full course of standard-dose induction chemotherapy) for any NHL;
  • To consolidate a first CR for individuals with diffuse large B-cell lymphoma and an International Prognostic Index score that predicts a low- or low-intermediate risk of relapse;
  • To consolidate a first CR for those with indolent NHL B-cell subtypes.
  • Tandem transplants are considered experimental/investigational, and therefore, non-covered, to treat individuals with any stage, grade, or subtype of NHL.
  • For individuals with peripheral T-cell lymphoma:
  • Autologous HSCT may be considered medically necessary to consolidate a first complete remission in *high-risk peripheral T-cell lymphoma.
  • Autologous or allogeneic HSCT (myeloablative or reduced-intensity conditioning) may be considered medically necessary as salvage therapy.
  • Allogeneic HSCT is considered experimental/investigational, and therefore, non-covered, to consolidate a first remission. Scientific evidence does not support this treatment.
  • *High-risk peripheral T-cell lymphoma is defined as one of the histologic subtypes as follows:
  • Nodal: peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), anaplastic lymphoma kinase negative anaplastic large cell lymphoma (ALK- ALCL) or angioimmunoblastic lymphoma (AIL). High-risk individuals may also include the rare patient with ALK+ALCL who is refractory to conventional chemotherapy.
  • Extranodal: T/NK cell lymphoma nasal type, enteropathy-type T-cell lymphoma, hepatosplenic T-cell lymphoma and subcutaneous panniculitis-like T-cell lymphoma.
  • RIC would be considered an option in individuals who meet criteria for an allogeneic stem-cell transplant (SCT) but whose age (typically older than 55 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, or prior intensive chemotherapy) preclude use of a standard conditioning regimen.
  • In individuals who qualify for a myeloablative allogeneic hematopoietic HSCT on the basis of overall health and disease status, allogeneic HSCT using either myeloablative or RIC may be considered. However, a myeloablative conditioning regimen with allogeneic HSCT may benefit younger individuals with good performance status and minimal comorbidities more than allogeneic HSCT with RIC.
  • Available scientific evidence does not permit conclusions concerning the effect of hematopoietic stem-cell transplantation for non-Hodgkin lymphomas for services considered experimental/investigational in this policy.

Procedure Codes

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

Diagnosis Codes

C82.00 C82.01 C82.02 C82.03 C82.04 C82.05 C82.06
C82.07 C82.08 C82.09 C82.10 C82.11 C82.12 C82.13
C82.14 C82.15 C82.16 C82.17 C82.18 C82.19 C82.20
C82.21 C82.22 C82.23 C82.24 C82.25 C82.26 C82.27
C82.28 C82.29 C82.30 C82.31 C82.32 C82.33 C82.34
C82.35 C82.36 C82.37 C82.38 C82.39 C82.40 C82.41
C82.42 C82.43 C82.44 C82.45 C82.46 C82.47 C82.48
C82.49 C82.50 C82.51 C82.52 C82.53 C82.54 C82.55
C82.56 C82.57 C82.58 C82.59 C82.60 C82.61 C82.62
C82.63 C82.64 C82.65 C82.66 C82.67 C82.68 C82.69
C82.80 C82.81 C82.82 C82.83 C82.84 C82.85 C82.86
C82.87 C82.88 C82.89 C82.90 C82.91 C82.92 C82.93
C82.94 C82.95 C82.96 C82.97 C82.98 C82.99 C83.00
C83.01 C83.02 C83.03 C83.04 C83.05 C83.06 C83.07
C83.08 C83.09 C83.10 C83.11 C83.12 C83.13 C83.14
C83.15 C83.16 C83.17 C83.18 C83.19 C83.30 C83.31
C83.32 C83.33 C83.34 C83.35 C83.36 C83.37 C83.38
C83.39 C83.50 C83.51 C83.52 C83.53 C83.54 C83.55
C83.56 C83.57 C83.58 C83.59 C83.70 C83.71 C83.72
C83.73 C83.74 C83.75 C83.76 C83.77 C83.78 C83.79
C83.80 C83.81 C83.82 C83.83 C83.84 C83.85 C83.86
C83.87 C83.88 C83.89 C83.90 C83.91 C83.92 C83.93
C83.94 C83.95 C83.96 C83.97 C83.98 C83.99 C84.40
C84.41 C84.42 C84.43 C84.44 C84.45 C84.46 C84.47
C84.48 C84.49 C84.60 C84.61 C84.62 C84.63 C84.64
C84.65 C84.66 C84.67 C84.68 C84.69 C84.70 C84.71
C84.72 C84.73 C84.74 C84.75 C84.76 C84.77 C84.78
C84.79 C84.90 C84.91 C84.92 C84.93 C84.94 C84.95
C84.96 C84.97 C84.98 C84.99 C84.A0 C84.A1 C84.A2
C84.A3 C84.A4 C84.A5 C84.A6 C84.A7 C84.A8 C84.A9
C84.Z0 C84.Z1 C84.Z2 C84.Z3 C84.Z4 C84.Z5 C84.Z6
C84.Z7 C84.Z8 C84.Z9 C85.10 C85.11 C85.12 C85.13
C85.14 C85.15 C85.16 C85.17 C85.18 C85.19 C85.20
C85.21 C85.22 C85.23 C85.24 C85.25 C85.26 C85.27
C85.28 C85.29 C85.80 C85.81 C85.82 C85.83 C85.84
C85.85 C85.86 C85.87 C85.88 C85.89 C85.90 C85.91
C85.92 C85.93 C85.94 C85.95 C85.96 C85.97 C85.98
C85.99 C86.0 C86.1 C86.2 C86.3 C86.4 C86.5
C86.6 C88.4

Table: Updated World Health Organization (WHO) Classification 2016

Mature B-cell neoplasms 

Chronic lymphocytic leukemia/small lymphocytic lymphoma

Monoclonal B-cell lymphocytosis*

B-cell prolymphocytic leukemia

Splenic marginal zone lymphoma

Hairy cell leukemia

Splenic B-cell lymphoma/leukemia, unclassifiable

  • Splenic diffuse red pulp small B-cell lymphoma 
  • Hairy cell leukemia-variant 

Lymphoplasmacytic lymphoma

  • Waldenström macroglobulinemia

Monoclonal gammopathy of undetermined significance (MGUS), IgM*

μ heavy-chain disease

γ heavy-chain disease

α heavy-chain disease

Monoclonal gammopathy of undetermined significance (MGUS), IgG/A*

Plasma cell myeloma

Solitary plasmacytoma of bone

Extraosseous plasmacytoma

Monoclonal immunoglobulin deposition diseases*

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

Nodal marginal zone lymphoma

  • Pediatric nodal marginal zone lymphoma 

Follicular lymphoma

  • In situ follicular neoplasia*
  • Duodenal-type follicular lymphoma*

Pediatric-type follicular lymphoma*

Large B-cell lymphoma with IRF4 rearrangement* 

Primary cutaneous follicle center lymphoma

Mantle cell lymphoma

  • In situ mantle cell neoplasia*

Diffuse large B-cell lymphoma (DLBCL), NOS

  • Germinal center B-cell type*
  • Activated B-cell type*

T-cell/histiocyte-rich large B-cell lymphoma

Primary DLBCL of the central nervous system (CNS)

Primary cutaneous DLBCL, leg type

EBV+ DLBCL, NOS*

EBV+ mucocutaneous ulcer* 

DLBCL associated with chronic inflammation

Lymphomatoid granulomatosis

Primary mediastinal (thymic) large B-cell lymphoma

Intravascular large B-cell lymphoma

ALK+ large B-cell lymphoma

Plasmablastic lymphoma

Primary effusion lymphoma

HHV8+ DLBCL, NOS* 

Burkitt lymphoma

Burkitt-like lymphoma with 11q aberration* 

High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements*

High-grade B-cell lymphoma, NOS*

B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma

Mature T and NK neoplasms 

T-cell prolymphocytic leukemia

T-cell large granular lymphocytic leukemia

Chronic lymphoproliferative disorder of NK cells 

Aggressive NK-cell leukemia

Systemic EBV+ T-cell lymphoma of childhood*

Hydroa vacciniforme–like lymphoproliferative disorder*

Adult T-cell leukemia/lymphoma

Extranodal NK-/T-cell lymphoma, nasal type

Enteropathy-associated T-cell lymphoma

Monomorphic epitheliotropic intestinal T-cell lymphoma*

Indolent T-cell lymphoproliferative disorder of the GI tract* 

Hepatosplenic T-cell lymphoma

Subcutaneous panniculitis-like T-cell lymphoma

Mycosis fungoides

Sézary syndrome

Primary cutaneous CD30+ T-cell lymphoproliferative disorders

  • Lymphomatoid papulosis
  • Primary cutaneous anaplastic large cell lymphoma

Primary cutaneous γδ T-cell lymphoma

Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma 

Primary cutaneous acral CD8+ T-cell lymphoma* 

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder* 

Peripheral T-cell lymphoma, NOS

Angioimmunoblastic T-cell lymphoma

Follicular T-cell lymphoma* 

Nodal peripheral T-cell lymphoma with TFH phenotype* 

Anaplastic large-cell lymphoma, ALK+

Anaplastic large-cell lymphoma, ALK−*

Breast implant–associated anaplastic large-cell lymphoma*

Provisional entities are listed in italics.

*Changes from the 2008 classification.

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