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Printer Friendly Version Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer

Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer

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 with or without whole body radiation therapy. Bone marrow 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 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. Cord blood is discussed in greater detail in the Placental and Umbilical Cord Blood as a Source of Stem Cells policy.

HSCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults continues to be largely experimental. Initial enthusiasm for the use of autologous transplant with the use of high-dose chemotherapy and stem cells for solid tumors has waned with the realization that dose intensification often fails to improve survival, even in tumors with a linear-dose response to chemotherapy. With the advent of reduced-intensity conditioning (RIC) allogeneic transplant, interest has shifted to exploring the generation of alloreactivity to metastatic solid tumors via a graft-versus-tumor effect of donor-derived T cells.

Epithelial Ovarian Cancer

Several different types of malignancies can arise in the ovary; epithelial carcinoma is the most common. Epithelial ovarian cancer is the fifth most common cause of cancer death in women. New cases and deaths from ovarian cancer in the United States in 2008 are estimated at 21,650 and 15,520. Most ovarian cancer patients present with widespread disease, and yearly mortality is approximately 65% of the incidence rate.

The current management of advanced epithelial ovarian cancer is cytoreductive surgery followed by combination chemotherapy. Approximately 75% of patients present with International Federation of Gynecology and Obstetrics (FIGO) stage III or IV ovarian cancer, and treated with the combination of paclitaxel and a platinum analog being the preferred regimen for newly diagnosed advanced disease. The use of platinum and taxanes has improved progression-free survival (PFS) and overall survival (OS) rates in advanced disease to 16–21 months and 32–57 months, respectively. However, most of these women develop recurrences and die of their disease as chemotherapy drug resistance leads to uncontrolled cancer growth.

High-dose chemotherapy has been investigated as a way to overcome drug resistance. However, limited data exist on this treatment approach, and the ideal patient population and best regimen remain to be established. Hematopoietic stem-cell transplantation has been studied in a variety of patient groups with ovarian cancer as follows:

to consolidate remission after initial treatment
to treat relapse after a durable response to platinum-based chemotherapy
to treat tumors that relapsed after less than 6 months
to treat refractory tumors

See Hematopoietic Stem-Cell Tranplantation in the Treatment of Germ-Cell Tumors medical policy for germ cell tumors of the ovary.

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 or allogeneic hematopoietic stem-cell transplantation is considered investigational to treat epithelial ovarian cancer.

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.

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: 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 # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)

7/14/2004: Code Reference section completed

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

10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted

3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy

12/21/2006: Policy reviewed, no changes

12/19/2007: Coding updated per 2008 CPT/HCPCS revisions

1/06/2009: Policy reviewed. No changes.

4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged. Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.

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

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

02/20/2013: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association Policy # 8.01.23

CODE REFERENCE

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

All codes billed for this procedure are considered investigational and not eligible for coverage.

Non-Covered Codes

Code Number	Description
CPT-4
38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition (added 7-14-2004)
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic (added 7-14-2004)
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous (added 7-14-2004)
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage (added 7-14-2004)
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing (added 7-14-2004)
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing (added 7-14-2004)
38210	Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion (added 7-14-2004)
38211	Transplant preparation of hematopoietic progenitor cells; tumor cell depletion (added 7-14-2004)
38212	Transplant preparation of hematopoietic progenitor cells; red blood cell removal (added 7-14-2004)
38213	Transplant preparation of hematopoietic progenitor cells; platelet depletion (added 7-14-2004)
38214	Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion (added 7-14-2004)
38215	Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer (added 7-14-2004) (Do not report 88180, 88182 in conjunction with 38207-38215)
38220	Bone marrow; aspiration only (added 7-14-2004)
38221	Bone marrow; biopsy, needle or trocar (added 7-14-2004)
38230	Bone marrow harvesting for transplantation (added 10/26/2005)
38240	Bone marrow or blood-derived peripheral stem cell transplantation; allogenic (added 7-14-2004)
38241	Bone marrow or blood-derived peripheral stem cell transplantation; autologous (added 7-14-2004)
38242	Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions (added 7-14-2004)
86812	HLA typing; A, B, or C (eg, A10, B7, B27), single antigen (added 7-14-2004)
86813	HLA typing; A, B, or C, multiple antigens (added 7-14-2004)
86816	HLA typing; DR/DQ, single antigen (added 7-14-2004)
86817	HLA typing; DR/DQ, multiple antigens (added 7-14-2004)
86821	HLA typing; lymphocyte culture, mixed (MLC) (added 7-14-2004)
86822	HLA typing; lymphocyte culture, primed (PLC) (added 7-14-2004)
86825	Human 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)
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 7-14-2004) (revised 1-1-2006)
96406	Chemotherapy administration; intralesional, more than 7 lesions (added 7-14-2004) (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 (added 7-14-2004)
96422	Chemotherapy administration, intra-arterial; infusion technique, up to one hour (added 7-14-2004)
96423	Chemotherapy administration, intra-arterial; infusion technique, each additional hour up to 8 hours (List separately in addition to code for primary procedure) (added 7-14-2004) (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 (added 7-14-2004)
96440	Chemotherapy administration into pleural cavity, requiring and including thoracentesis (added 7-14-2004)
96445	Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis (added 7-14-2004)
96450	Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture (added 7-14-2004)
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
41.01, 41.02, 41.03	Bone marrow transplant code range (added 10-26-2005)
41.04, 41.05, 41.07, 41.08	Hematopoietic stem cell transplant code range (added 7-14-2004)
41.09	Autologous bone marrow transplant with purging (added 10-26-2005)
41.91	Aspiration of bone marrow from donor for transplant (added 7-14-2004)
99.25	Injection or infusion of cancer chemotherapeutic substance (added 7-14-2004)
99.79	Other apheresis ( harvest) of stem cells (added 7-14-2004) (description changed 10-26-2005)
ICD-9 Diagnosis

HCPCS - To report antineoplastic drugs, see code range J9000-J9999 in the HCPCS Level II manual. (added 10-26-2005)
G0363	Irrigation of implanted venous access device for drug delivery systems (do not report C0363 if an injection or infusion is provided on the same day) (effective 1-1-2005) (added 10-26-2005)
G0364	Bone 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)
Q0083	Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit (added 7-14-2004)
Q0084	Chemotherapy administration by infusion technique only, per visit (added 7-14-2004)
Q0085	Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit (added 7-14-2004)
S2140	Cord blood harvesting for transplantation, allogeneic (Added 04-26-2010)
S2142	Cord blood-derived stem-cell transplantation, allogeneic (Added 04-26-2010)
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 (added 7-14-2004)

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