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Hematopoietic Cell Transplantation for Solid Tumors of Childhood

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

Description

Hematopoietic cell transplantation (HCT) refers to a procedure in which hematopoietic stem 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. Stem cells may be obtained from the transplant recipient (autologous HCT) or can be harvested from a donor (allogeneic HCT). Stem cells may be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates.

Criteria

Autologous HCT may be considered medically necessary for ANY ONE the following indications:

  • Initial treatment of high-risk neuroblastoma; or
  • Recurrent or refractory neuroblastoma; or
  • Initial treatment of high-risk Ewing’s sarcoma; or
  • Recurrent or refractory Ewing’s sarcoma;or
  • Metastatic retinoblastoma.

High-risk neuroblastoma is characterized by age older than one year, disseminated disease, MYCN oncogene amplification, and unfavorable histopathologic findings. This list is not all inclusive. Tandem autologous-autologous HCT may be considered medically necessary for high risk neuroblastoma when ALL of the following have been met:

  • Individual does not have a concurrent condition/disease, which would seriously compromise the chance of attaining a durable complete remission with this therapy; and 
  • Individual has stem cell product that meets infusion criteria of viability and neuroblastoma stem cell contamination (less than one (1) neuroblastoma cell per 100,000 peripheral blood progenitor cells or less than 10 % morphological evidence bone marrow involvement) prior to transplant.

A maximum of three (3) tandem autologous HCTs are covered when it is considered medically necessary for the treatment of high-risk neuroblastoma.

Autologous HCT is considered experimental/investigational and, therefore non-covered as initial treatment of low- or intermediate-risk neuroblastoma, initial treatment of low- or intermediate-risk Ewing’s sarcoma, and for other solid tumors of childhood including, but not limited, to the following:

  • Rhabdomyosarcoma; or
  • Wilms tumor; or
  • Osteosarcoma; or
  • Retinoblastoma without metastasis.

There is inadequate evidence in peer-reviewed medical literature demonstrating the effectiveness of autologous cell transplantation as initial treatment of low- or intermediate-risk neuroblastoma, initial treatment of low- or intermediate-risk Ewing’s sarcoma, and other solid tumors of childhood.

Tandem autologous HCT is considered experimental/investigational and, therefore, non-covered for the treatment of all other types of pediatric solid tumors except high-risk neuroblastoma, as noted above. There is inadequate evidence in peer-reviewed medical literature demonstrating the effectiveness of tandem autologous stem cell transplantation in these cases.

Procedure Codes

38204 38205 38206 38208 38209 38210 38211
38212 38213 38214 38215 38220 38221 38232
38241 86812 86813 86816 86817 86821 S2150

Allogeneic (myeloablative or nonmyeloablative) HCT is considered experimental/investigational and, therefore, non-covered for treatment of pediatric solid tumors. There is inadequate evidence in peer-reviewed literature demonstrating the effectiveness of allogeneic cell transplantation for the treatment of pediatric solid tumors.

Salvage allogeneic HCT for pediatric solid tumors that relapse after autologous transplant or fail to respond is considered experimental/investigational and, therefore, non-covered. There is inadequate evidence in peer-reviewed literature demonstrating the effectiveness of salvage allogeneic cell transplantation for the treatment of pediatric solid tumors that relapse or fail to respond to autologous cell transplantation.

Procedure Codes

38230 38240 38242 S2150

Diagnosis Codes

Covered Diagnosis Codes for Autologous HCT for Procedure Codes: 38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38232, 38241, 86812, 86813, 86816, 86817, 86821, S2150

C40.00 C40.01 C40.02 C40.10 C40.11 C40.12 C40.20
C40.21 C40.22 C40.30 C40.31 C40.32 C40.80 C40.81
C40.82 C40.90 C40.91 C40.92 C41.0 C41.1 C41.2
C41.3 C41.4 C41.9 C74.00 C74.01 C74.02 C74.10
C74.11 C74.12 C74.90 C74.91 C74.92    

Non-Covered Diagnosis Codes (Including But Not Limited To) for Autologous HCT for Procedure Codes: 38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38232, 38241, 86812, 86813, 86816, 86817, 86821, S2150

C47.0 C47.10 C47.11 C47.12 C47.20 C47.21 C47.22
C47.3 C47.4 C47.5 C47.6 C47.8 C47.9 C49.0
C49.4 C49.5 C49.6 C49.8 C49.9 C64.1 C64.2
C64.9 C65.1 C65.2 C65.9 C69.20 C69.21 C69.22

Non-Covered Diagnosis Codes (Including But Not Limited To) for Allogeneic  HCT for Procedure Codes: 38230, 38240, 38242, S2150

C40.00 C40.01 C40.02 C40.10 C40.11 C40.12 C40.20
C40.21 C40.22 C40.30 C40.31 C40.32 C40.80 C40.81
C40.82 C40.90 C40.91 C40.92 C41.0 C41.1 C41.2
C41.3 C41.4 C41.9 C47.0 C47.10 C47.11 C47.12
C47.20 C47.21 C47.22 C47.3 C47.4 C47.5 C47.6
C47.8 C47.9 C49.0 C49.10 C49.11 C49.12 C49.20
C49.21 C49.22 C49.3 C49.4 C49.5 C49.6 C49.8
C49.9 C64.1 C64.2 C64.9 C65.1 C65.2 C65.9
C69.20 C69.21 C69.22 C74.00 C74.01 C74.02 C74.10
C74.11 C74.12 C74.90 C74.91 C74.92

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