This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma

Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma

 

DESCRIPTION

 Hematopoietic Stem-Cell Transplantation 
Hematopoietic stem-cell transplantation (HSCT) 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. Bone-marrow stem cells may be obtained from the transplant recipient (i.e., autologous SCT) or from a donor (i.e., allogeneic SCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates.

Hematopoietic Stem-Cell Transplantation for Brain Tumors
Autologous HSCT allows for escalation of chemotherapy doses above those limited by myeloablation and has been tried in patients with high-risk brain tumors in an attempt to eradicate residual tumor cells and improve cure rates. The use of allogeneic HSCT for solid tumors does not rely on escalation of chemotherapy intensity and tumor reduction, but rather on a graft-versus-tumor effect. Allogeneic HSCT is uncommonly used in solid tumors, and may be used if an autologous source cannot be cleared of tumor or cannot be harvested.

CNS Embryonal Tumors
Classification of brain tumors is based on both histopathologic characteristics of the tumor and location in the brain. Central nervous system (CNS) embryonal tumors are more common in children and are the most common brain tumor in childhood. They are primarily composed of undifferentiated round cells, with divergent patterns of differentiation. It has been proposed that these tumors be merged under the term “primitive neuroectodermal tumor” (PNET), however, histologically similar tumors in different locations in the brain demonstrate different molecular genetic alterations. Embryonal tumors of the CNS include medulloblastoma, medulloepithelioma, supratentorial PNETs (pineoblastoma, cerebral neuroblastoma, ganglioneuroblastoma), ependymoblastoma, and atypical teratoid/rhabdoid tumor (AT/RT).

Medulloblastomas account for 20% of all childhood CNS tumors. The other types of embryonal tumors are rare by comparison. Surgical resection is the mainstay of therapy with the goal being gross total resection with adjuvant radiation therapy, as medulloblastomas are very radiosensitive. Treatment protocols are based on risk stratification, as average or high risk. The average-risk group includes children older than 3 years, without metastatic disease, and with tumors that are totally or near totally resected (<1.5 cm² of residual disease). The high-risk group includes children aged 3 years or younger, or with metastatic disease, and/or subtotal resection (>1.5 cm2 of residual disease).

Current standard treatment regimens for average-risk medulloblastoma (postoperative craniospinal irradiation with boost to the posterior fossa followed by 12 months of chemotherapy) have resulted in 5-year overall survival (OS) rates of 80% or better.  For high-risk medulloblastoma treated with conventional doses of chemotherapy and radiotherapy, the average event-free survival at 5 years ranges from 34%–40% across studies.  Fewer than 55% of children with high-risk disease survive longer than 5 years. The treatment of newly diagnosed medulloblastoma continues to evolve, and in children under the age of 3, because of the concern of the deleterious effects of craniospinal radiation on the immature nervous system, therapeutic approaches have attempted to delay and sometimes avoid the use of radiation, and have included trials of higher-dose chemotherapeutic regimens with autologous HSCT.

Supratentorial PNETs (sPNET) are most commonly located in the cerebral cortex and pineal region. The prognosis for these tumors is worse than for medulloblastoma, despite identical therapies.  After surgery, children are usually treated similarly to children with high-risk medulloblastoma. Three- to 5-year OS rates of 40%–50% have been reported, and for patients with disseminated disease, survival rates at 5 years range from 20%–30%.

Recurrent childhood CNS embryonal tumor is not uncommon, and depending on which type of treatment the patient initially received, autologous HSCT may be an option. For patients who receive high-dose chemotherapy and autologous HSCT for recurrent embryonal tumors, objective response is 50%–75%; however, long-term disease control is obtained in fewer than 30% of patients, and is seen primarily in patients in first relapse with localized disease at the time of relapse.

Ependymoma
Ependymoma is a neuroepithelial tumor that arises from the ependymal lining cell of the ventricles and is therefore usually contiguous with the ventricular system. In children, the tumor typically arises intracranially, while in adults, a spinal cord location is more common. Ependymomas have access to the cerebrospinal fluid and may spread throughout the entire neuroaxis.  Ependymomas are distinct from ependymoblastomas due to their more mature histologic differentiation. Initial treatment of ependymoma consists of maximal surgical resection followed by radiotherapy. Chemotherapy usually does not play a role in the initial treatment of ependymoma. However, disease relapse is common, typically occurring at the site of origin. Treatment of recurrence is problematic; further surgical resection or radiation therapy is usually not possible. Given the poor response to conventional-dose chemotherapy, high-dose chemotherapy with autologous HSCT has been investigated as a possible salvage therapy.

Note: Other CNS tumors include astrocytoma, oligodendroglioma, and glioblastoma multiforme. However, these tumors arise from glial cells and not neuroepithelial cells. Thus, they are not considered PNETs. These tumors are considered separately in the Autologous Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas medical policy.

Note: Due to their neuroepithelial origin, peripheral neuroblastoma and Ewing's sarcoma may be considered PNETs. However, these peripheral tumors are considered separately in the Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood medical 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.

Embryonal tumors of the CNS 

Autologous hematopoietic stem-cell transplantation may be considered medically necessary to treat recurrent embryonal tumors of the CNS.

Autologous hematopoietic stem-cell transplantation may be considered medically necessary as consolidation therapy for previously untreated embryonal tumors of the central nervous system (CNS) that show partial or complete response to induction chemotherapy, or stable disease after induction therapy (see Policy Guidelines).

Tandem autologous hematopoietic stem-cell transplant is investigational to treat embryonal tumors of the CNS.

Allogeneic hematopoietic stem-cell transplantation is investigational to treat embryonal tumors of the CNS.


Ependymoma 
Autologous, tandem autologous and allogeneic hematopoietic stem-cell transplant is investigational to treat ependymoma.

 

POLICY EXCEPTIONS

 For Federal Employee Program (FEP) subscribers, the Service Benefit Plan includes specific conditions in which autologous or allogeneic blood or marrow stem cell transplants would be considered eligible for coverage.

For State and School Employee subscribers, all bone marrow/stem cell transplants must be certified as medically necessary by the Plan’s Utilization Review Vendor, CareAllies. No benefits will be provided for any transplant procedure unless prior approval for the transplant is obtained from CareAllies.

 

POLICY GUIDELINES

 Residual tumor is defined as a tumor that does not achieve a complete response after initial therapy. This includes partial responses (i.e., those less than complete but greater than or equal to 50% response) and refractory disease (i.e., less than a 50% response).

In general, use of autologous hematopoietic stem-cell transplantation for previously untreated medulloblastoma has shown no survival benefit for those patients considered to be at average risk (i.e., patient age older than 3 years, without metastatic disease, and with total or near total surgical resection [<1.5 cm2 residual tumor]) when compared to conventional therapies.

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: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)

6/25/2004: Code Reference section completed

11/18/2004: Review by MPAC, no changes

10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table

3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy

5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements

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

5/21/2008: Policy reviewed, no changes

04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.”  The term “PNET” was changed to “embryonal tumors” throughout the policy.  Policy description updated. Policy statement changed to state that autologous consolidation therapy in patients with previously untreated embryonal tumors showing complete or partial response to, or stable disease after, induction therapy is now considered medically necessary. Supporting explanation added to the policy guidelines. Policy statement reworded and ependymoma and embryonal CNS tumors are addressed separately. FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826.  Removed CPT codes 86812, 86813, 86816, 86817, 86821, and 86822 from the non-covered table. Added HCPCS S2140 and S2142 to the non-covered table. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007.

12/28/2010:  Policy reviewed; no changes.

01/17/2012:  Policy reviewed; no changes.

03/13/2013:  Policy reviewed; no changes.

 

SOURCE(S)

 Blue Cross Blue Shield Association Policy # 8.01.28

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.  

Covered Codes

Code Number

Description

CPT-4

38206Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous (added 6-25-2004)
38207Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage (added 6-25-2004)
38208Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing (added 6-25-2004)
38209Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing (added 6-25-2004)
38210Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion (added 6-25-2004)
38211Transplant preparation of hematopoietic progenitor cells; tumor cell depletion (added 6-25-2004)
38212Transplant preparation of hematopoietic progenitor cells; red blood cell removal (added 6-25-2004)
38213Transplant preparation of hematopoietic progenitor cells; platelet depletion (added 6-25-2004)
38214Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion (added 6-25-2004)
38215

Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer (added 6-25-2004)

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

38220 Bone marrow; aspiration only (added 6-25-2004)
38221Bone marrow; biopsy, needle or trocar (added 6-25-2004)
38230Bone marrow harvesting for transplantation (added 10-26-2005) 
38241Bone marrow or blood-derived peripheral stem cell transplantation; autologous (added 6-25-2004)
86812 HLA typing; A, B, or C (eg, A10, B7, B27), single antigen (added 6-25-2004)
86813HLA typing; A, B, or C, multiple antigens (added 6-25-2004)
86816HLA typing; DR/DQ, single antigen (added 6-25-2004)
86817 HLA typing; DR/DQ, multiple antigens (added 6-25-2004)
86821 HLA typing; lymphocyte culture, mixed (MLC) (added 6-25-2004)
86822HLA typing; lymphocyte culture, primed (PLC) (added 6-25-2004)
86825Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); first serum sample or dilution (New 1-1-2010)
86826

Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution (List separately in addition to primary procedure) (New 1-1-2010)

96401Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic (new 1-1-2006)
96402Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic (new 1-1-2006)
96405Chemotherapy administration; intralesional, up to and including 7 lesions (added 6-25-2004) (revised 1-1-2006)
96406Chemotherapy administration; intralesional, more than 7 lesions (added 6-25-2004) (revised 1-1-2006)
96409Chemotherapy administration; intravenous, push technique, single or initial substance/drug (new 1-1-2006)
96411Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) (new 1-1-2006)
96413Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug (new 1-1-2006)
96415Chemotherapy administration, intravenous infusion technique; each additional hour, 1 to 8 hours, (List separately in addition to code for primary procedure) (new 1-1-2006)
96416Chemotherapy 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)
96417Chemotherapy 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)
96420Chemotherapy administration, intra-arterial; push technique (added 6-25-2004)
96422Chemotherapy administration, intra-arterial; infusion technique, up to one hour (added 6-25-2004)
96423 Chemotherapy administration, intra-arterial; infusion technique, each additional hour up to 8 hours (List separately in addition to code for primary procedure) (added 6-25-2004) (revised 1-1-2006)
96425Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump (added 6-25-2004)
96440Chemotherapy administration into pleural cavity, requiring and including thoracentesis (added 6-25-2004)
96445Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis (added 6-25-2004)
96450 Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture (added 6-25-2004)
96521Refilling and maintenance of portable pump (new 1-1-2006)
96522Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) (new 1-1-2006)
96523Irrigation of implanted venous access device for drug delivery systems (new 1-1-2006)

ICD-9 Procedure

41.01Autologous bone marrow transplant without purging (added 10-26-2005)
41.04, 41.07Hematopoietic stem cell transplant code range (added 6-25-2004)
41.09Autologous bone marrow transplant with purging (added 10-26-2005) 
99.25 Injection or infusion of cancer chemotherapeutic substance (added 6-25-2004)

99.79

Other therapeutic apheresis (added 6-25-2004)

ICD-9 Diagnosis

191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 192.0, 192.1, 192.2, 192.3, 192.8, 192.9Malignant neoplasm of brain and other unspecified parts of nervous system (added 6-25-2004)

HCPCS - To report antineoplastic drugs, see code range J9000 - J9999 in the HCPCS Level II manual. (added 10-20-2005)

G0363Irrigation 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) (added 10-26-2005)
G0364Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service (effective 1-1-2005) (added 10-26-2005)
Q0083Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit (added 6-25-2004)
Q0084Chemotherapy administration by infusion technique only, per visit (added 6-25-2004)
Q0085Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit (added 6-25-2004)
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 or pre-and post-transplant care in the global definition (added 6-25-2004)

Note: Only Autologous stem-cell support is covered. See   POLICY section.

 

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure. 

Non-Covered Codes

Code Number

Description

CPT-4

38204Management of recipiant hematopoietic progenitor cell donor search and cell aquistion (added 06-25-2004) (moved to non-covered 10-26-2005)
38205Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic (added 6-25-2004)
38240Bone marrow or blood-derived peripheral stem cell transplantation; allogenic (added 6-25-2004)
38242Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions (added 6-25-2004)

ICD-9 Procedure

41.02, 41.03Allogeneic bone marrow transplant code range (added 10-26-2005)
41.05 Allogeneic hematopoietic stem cell transplant without purging (added 6-25-2004)
41.08 Allogeneic hematopoietic stem cell transplant with purging (added 6-25-2004)

41.91

Aspiration of bone marrow from donor for transplant (added 6-25-2004)

ICD-9 Diagnosis

    

HCPCS

S2140 Cord blood harvesting for transplantation, allogeneic (Added 04-26-2010) 
S2142 Cord blood-derived stem-cell transplantation, allogeneic (Added 04-26-2010)

 

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