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Hematopoietic Cell Transplantation for Solid Tumors of Childhood

Section: Surgery
Effective Date: January 01, 2020
Revised Date: February 25, 2020
Last Reviewed: March 16, 2020

Description

Hematopoietic cell transplantation (HCT) refers to a procedure in which hematopoietic stem cells are infused to restore bone marrow function in cancer individuals 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 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 stem-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

38222

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, 38222, 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, 38222, 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

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Reformatting to HMK policy. HMK has additional criteria under tandem

12-17-2019 no change in Criteria, changes in Wording

03-16-2020 Internal Medical Policy Committee 03-16-2020 Coding update only.

Links

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.