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DESCRIPTIONHigh-Dose Chemotherapy (HDC) involves the administration of cytotoxic agents using doses several times greater than the standard therapeutic dose. In some cases, whole body or localized radiotherapy is also given and is included in the term HDC when applicable. The most significant side effect is marrow ablation and thus HDC is accompanied by a reinfusion of stem cells in order to repopulate the bone marrow.
The 3 potential donors of stem cells are:
POLICYNo 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.
High-Dose Chemotherapy with Hematopoietic Stem Cell for Malignancies is considered medically necessary for patients meeting the following:
See Single or Tandem Courses of High-Dose Chemotherapy plus Hematopoietic Stem-Cell Support to Treat Multiple Myeloma medical policy after dates of service 1-26-2004 (added 1-27-2004)
Evaluations of HDC with hematopoietic stem-cell support concluded that the TEC criteria were not met for the following cancers. Therefore, HDC/SCS is considered investigational for the following:
POLICY GUIDELINESInvestigative 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/2000: Revised; indications for autoimmune diseases, including multiple sclerosis considered investigational
2/17/2000: Note update of DESCRIPTION and POLICY revisions
5/2000: Application for High-Dose Chemotherapy and Radiation Therapy followed by Allogeneic Transplantation for multiple myeloma reviewed by MPAC; investigational status maintained
6/1/2000: Note POLICY HISTORY update
11/2000: MPAC reviewed HDC/AuSCS treatment in patients with breast cancer; case-by-case review
2/14/2001: ICD-9 procedure code 41.07-41.09 added
2/7/2002: "Its use is promising, the data remains inconclusive and umbilical cord blood is considered investigational as a source of stem cells." has been deleted
4/10/2002: Investigative definition added
5/1/2002: Type of Service and Place of Service deleted
3/18/2003: Code Reference section updated, code ranges 86812-86822, 96400-96450, Q0083-Q0085, J9000-J9999 listed separately
1/27/2004: Hyperlink added for separate policy "Single or Tandem Courses of High-Dose Chemotherapy plus Hematopoietic Stem-Cell Support to Treat Multiple Myeloma"
3/25/2004: Reviewed by MPAC, approval to develop separate medical policy and aligned with BCBSA policy # 8.01.32, 8.01.26, 8.01.30, 8.01.29, 8.01.20, 8.01.28, 8.01.34, 8.01.35, 8.01.23, 8.01.27, 8.01.15, 8.01.24, 8.01.25, 8.01.21, 8.01.31, hyperlinks inserted for appropriate medical policies, Sources updated
7/14/2004: Code Reference section updated, CPT 38230, 38231, 86915 deleted, CPT 38220, 38221, 96520, 96530 added, CPT 38208, 38209 description revised to be consistent with AMA, ICD-9 procedure code 41.01, 41.02, 41.03, 41.06, 41.09 deleted, ICD-9 procedure code 99.25 description revised, HCPCS J9180 deleted code 2004, HCPCS G0265, G0266, J9098, J9178, J9263, J9395, S2150 added
11/18/2004: Reviewed by MPAC, “HDC/AuSCS (High Dose Chemotherapy with Autologous Stem Cell Support) is considered medically necessary to treat adult patients in first remission only, or in pediatric patients in first or subsequent remission, who are high risk for relapse and who do not have an acceptable allogeneic donor available.” changed to “HDC/AuSCS (High Dose Chemotherapy with Autologous Stem Cell Support) is considered medically necessary to treat patients in remission,” “Hodgkin's disease (lymphoma): HDC/AuSCS, allo-BMT, and allo-PBSC are considered medically necessary when used to treat patients with stage III or stage IV of the following International Working Formulation (IWF) classes: including the table AND For IWF classes B-D, HDC/AuSCS and allo-BMT are considered medically necessary only for those patients who have failed primary therapy and have not transformed to a higher grade. These therapies are considered investigational for patients in a first complete remission or for those who have relapsed NHL with transformation.” deleted, “Multiple myeloma: Allo-BMT and Allo-PBSC are considered investigational to treat any patients with multiple myeloma (i.e., newly diagnosed, responsive, or refractory disease) (added 5/2000).” changed to medically necessary
7/15/2005: Code Reference section updated, CPT code 38230 added, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated; ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy.
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
SOURCE(S)A search of the literature was completed through the MEDLINE database for the period of January 1992 through February 1998. The search strategy focused on references containing the following Medical Subject Headings:
Research was limited to English-language journals on humans.
TEC Assessment, 1998, 1997, 1990, 1989, 1986
Hayes Medical Technology Directory
Blue Cross Blue Shield Association policy # 8.01.32, 8.01.26, 8.01.30, 8.01.29, 8.01.20, 8.01.28, 8.01.34, 8.01.35, 8.01.23, 8.01.27, 8.01.15, 8.01.24, 8.01.25, 8.01.21, 8.01.31 (added 3-25-2004)
CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some codes may be variable and coverage will be based on the clinical indication for the service.