Print Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

 

DESCRIPTION

Hematopoietic Stem-Cell Transplantation

Hematopoietic stem-cell transplantation (SCT) 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. Bone marrow stem cells may be obtained from the transplant recipient (autologous SCT) can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta 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.

Preparative Conditioning for Hematopoietic Stem-Cell Transplantation

Autologous SCT necessitates myeloablative chemotherapy to eradicate cancerous cells from the blood and bone marrow, thus permitting subsequent engraftment and repopulation of bone marrow space with presumably normal hematopoietic progenitor cells. As a consequence, autologous SCT is typically performed as consolidation therapy when the patient’s disease is in complete remission. Patients who undergo autologous SCT are susceptible to chemotherapy-related toxicities and opportunistic infections prior to engraftment, but not graft-versus-host disease.

Astrocytomas and Gliomas

Diffuse fibrillary astrocytomas are the most common type of brain tumor in adults. These tumors are classified histologically into 3 grades of malignancy: grade II astrocytoma, grade III anaplastic astrocytoma, and grade IV glioblastoma multiform. Oligodendrogliomas are diffuse neoplasms that are clinically and biologically most closely related to diffuse fibrillary astrocytomas. However, these tumors generally have better prognoses than diffuse astrocytomas, with mean survival times of 10 years versus 2–3 years. In addition, oligodendrogliomas appear to be more chemosensitive than other types of astrocytomas. Glioblastoma multiforme is the most malignant stage of astrocytoma, with survival times of less than 2 years for most patients.

Treatment of primary brain tumors focuses on surgery, either with curative intent or optimal tumor debulking. Surgery may be followed by radiation therapy and/or chemotherapy. Survival after chemoradiotherapy is largely dependent on the extent of residual tumor after surgical debulking. Therefore, tumors arising in the midline, basal ganglia, or corpus callosum or those arising in the eloquent speech or motor areas of the cortex, which typically cannot be extensively resected, have a particularly poor outcome. Treatment of children younger than 3 years is complicated by the long-term effects of radiation therapy on physical and intellectual function. Therefore, in young children, CNS radiation is avoided whenever possible.

Note: Astrocytomas and gliomas arise from the glial cells. Tumors arising from the neuroepithelium constitute a separate category of malignancies that include CNS neuroblastoma, medulloblastoma, ependymoblastomas, and pinealblastomas. Collectively these tumors may be referred to as primitive neuroectodermal tumors (PNETs). Ependymomas also arise from the neuroepithelium but, because of their more mature histologic appearance, are not considered a member of the PNET family. The use of high-dose chemotherapy in tumors arising from the neuroepithelium is addressed separately in the Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma policy.

 

POLICY

No benefits will be provided for a covered transplant procedure or a transplant evaluation unless the Member receives prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi.

Autologous hematopoietic stem-cell transplantation is investigational as a treatment of malignant astrocytomas and gliomas.(The latter diagnosis includes both glioblastoma multiforme and oligodendroglioma.)

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31

6/25/2004: Code Reference section completed

11/18/2004: Reviewed by MPAC; no changes

10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added

3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy.

9/18/2007: Policy reviewed, no changes

12/20/2007: Coding updated per 2008 CPT/HCPCS revisions

8/22/2008: Description section updated; policy statement unchanged

4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 

10/21/2010: Policy reviewed; no changes.

10/05/2011: Policy reviwed; no changes.

11/30/2012: Policy reviwed; no changes.

04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section.

 

SOURCE(S)

Blue Cross Blue Shield Association Policy # 8.01.31

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

Code Number

Description

CPT-4

38204

Management of recipient hematopoietic progenitor cell donor search and cell acquisition

38205

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic

38206

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous

38207

Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

38208

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing

38209

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing

38210

Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion

38211

Transplant preparation of hematopoietic progenitor cells; tumor cell depletion

38212

Transplant preparation of hematopoietic progenitor cells; red blood cell removal

38213

Transplant preparation of hematopoietic progenitor cells; platelet depletion

38214

Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion

38215

Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer

(Do not report 88180, 88182 in conjunction with 38207-38215) 

38220

Bone marrow; aspiration only

38221

Bone marrow; biopsy, needle or trocar

38230

Bone marrow harvesting for transplantation

38240

Bone marrow or blood-derived peripheral stem cell transplantation; allogenic

38241

Bone marrow or blood-derived peripheral stem cell transplantation; autologous

38242

Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions

86812

HLA typing; A, B, or C (eg, A10, B7, B27), single antigen

86813

HLA typing; A, B, or C, multiple antigens

86816

HLA typing; DR/DQ, single antigen

86817

HLA typing; DR/DQ, multiple antigens

86821

HLA typing; lymphocyte culture, mixed (MLC)

86822

HLA typing; lymphocyte culture, primed (PLC)

86825

HLA crossmatch, non-cytotoxic (eg, using flow cytometry); first serum sample or dilution  (new 1-1-2010)

86826

HLA crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution  (new 1-1-2010)

96401

Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic (new 1-1-2006)

96402

Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic (new 1-1-2006)

96405

Chemotherapy administration ; intralesional, up to and including 7 lesions (added 6-25-2004) (revised 1-1-2006)

96406

Chemotherapy administration; intralesional, more than 7 lesions (added 6-25-2004) (revised 1-1-2006)

96409

Chemotherapy administration; intravenous, push technique, single or initial substance/drug (new 1-1-2006)

96411

Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) (new 1-1-2006)

96413

Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug (new 1-1-2006)

96415

Chemotherapy administration, intravenous infusion technique; each additional hour, 1 to 8 hours, (List separately in addition to code for primary procedure) (new 1-1-2006)

96416

Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump (new 1-1-2006)

96417

Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure) (new 1-1-2006)

96420

Chemotherapy administration, intra-arterial; push technique

96422

Chemotherapy administration, intra-arterial; infusion technique, up to one hour

96423

Chemotherapy administration, intra-arterial; infusion technique,  each additional hour up to 8 hours (List separately in addition to code for primary procedure) (revised 1-1-2006)

96425

Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump

96440

Chemotherapy administration into pleural cavity, requiring and including thoracentesis

96445

Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis

96450

Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture

96521

Refilling and maintenance of portable pump (new 1-1-2006)

96522

Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) (new 1-1-2006)

96523

Irrigation of implanted venous access device for drug delivery systems (new 1-1-2006)

ICD-9 Procedure

41.00, 41.01

Bone marrow transplant code range

41.04, 41.07

Hematopoietic stem cell transplant code range

41.09

Autologous bone marrow transplant with purging

41.91 

Aspiration of bone marrow from donor for transplant

99.25 

Injection or infusion of cancer chemotherapeutic substance

99.79

Other therapeutic apheresis

ICD-9 Diagnosis

  

  

HCPCS - To report antineoplastic drugs, see code range J9000-J9999 in the HCPCS Level II manual (added 10/26/2005)

G0265 

Cryopreservation, freezing and storage of cells for therapeutic use, each cell line  (deleted 12-31-2007) 

G0266

Thawing and expansion of frozen cells for therapeutic use, each aliquot  (deleted 12-31-2007) 

G0267

Bone marrow or peripheral stem cell harvest, modification or treatment to eliminate cell type(s) (e.g., t-cells, metastatic carcinoma) (deleted 12-31-2007) 

G0363

Irrigantion of implanted venous access device for drug delivery systems (do not report G0363 if an injection or infusion is provided on the same day) (effective 1/1/2005)

G0364

Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service (effective 1-1-2005)

Q0083

Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit

Q0084

Chemotherapy administration by infusion technique only, per visit

Q0085

Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit

S2150

Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including pheresis and cell preparation/storage; marrow ablative therapy; drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition

 

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