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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 HCT) or from a donor (allogeneic HCT). 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 (GVHD). Cord blood is discussed in greater detail in the Placental and Umbilical Cord Blood as a Source of Stem Cells policy.

Immunologic compatibility between infused hematopoietic stem cells and the recipient is not an issue in autologous HSCT. However, immunologic compatibility between donor and patient is a critical factor for achieving a good outcome of allogeneic HSCT. Compatibility is established by typing of human leukocyte antigens (HLA) using cellular, serologic, or molecular techniques. HLA refers to the tissue type expressed at the Class I and Class II loci on chromosome 6. Depending on the disease being treated, an acceptable donor will match the patient at all or most of the HLA loci (with the exception of umbilical cord blood).

Conventional Preparative Conditioning for Hematopoietic Stem Cell Transplantation

The success of autologous HSCT is predicated on the ability of cytotoxic chemotherapy with or without radiation to eradicate cancerous cells from the blood and bone marrow. This permits subsequent engraftment and repopulation of bone marrow space with presumably normal hematopoietic stem cells obtained from the patient prior to undergoing bone marrow ablation. As a consequence, autologous HSCT is typically performed as consolidation therapy when the patient’s disease is in complete remission. Patients who undergo autologous HSCT are susceptible to chemotherapy-related toxicities and opportunistic infections prior to engraftment, but not GVHD.

The conventional (“classical”) practice of allogeneic HSCT involves administration of cytotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to destroy endogenous hematopoietic capability in the recipient. The beneficial treatment effect in this procedure is due to a combination of initial eradication of malignant cells and subsequent graft-versus-malignancy (GVM) effect mediated by non-self immunologic effector cells that develop after engraftment of allogeneic stem cells within the patient’s bone marrow space. While the slower GVM effect is considered to be the potentially curative component, it may be overwhelmed by extant disease without the use of pretransplant conditioning. However, intense conditioning regimens are limited to patients who are sufficiently fit medically to tolerate substantial adverse effects that include pre-engraftment opportunistic infections secondary to loss of endogenous bone marrow function and organ damage and failure caused by the cytotoxic drugs. Furthermore, in any allogeneic HSCT, immunosuppressant drugs are required to minimize graft rejection and GVHD, which also increases susceptibility of the patient to opportunistic infections.

Reduced-Intensity Conditioning for Allogeneic Stem-Cell Transplantation

Reduced-intensity conditioning (RIC) refers to the pretransplant use of lower doses or less intense regimens of cytotoxic drugs or radiation than are used in traditional full-dose myeloablative conditioning treatments. The goal of RIC is to reduce disease burden, but also to minimize as much as possible associated treatment-related morbidity and non-relapse mortality (NRM) in the period during which the beneficial GVM effect of allogeneic transplantation develops. Although the definition of RIC remains arbitrary, with numerous versions employed, all seek to balance the competing effects of NRM and relapse due to residual disease. RIC regimens can be viewed as a continuum in effects, from nearly totally myeloablative, to minimally myeloablative with lymphoablation, with intensity tailored to specific diseases and patient condition. Patients who undergo RIC with allogeneic HSCT initially demonstrate donor cell engraftment and bone marrow mixed chimerism. Most will subsequently convert to full-donor chimerism, which may be supplemented with donor lymphocyte infusions to eradicate residual malignant cells.

For the purposes of this Policy, the term reduced-intensity conditioning will refer to all conditioning regimens intended to be non-myeloablative, as opposed to fully myeloablative (traditional) regimens.

Hodgkin Lymphoma (HL)

HL is a relatively uncommon B-cell lymphoma.  In 2008, an estimated 8,220 new diagnoses and 1,350 deaths will occur in the U.S. The disease has a bimodal distribution, with most patients diagnosed between the ages of 15 and 30 years, with a second peak in adults aged 55 and older.

The World Health Organization (WHO) classification divides HL into 2 main types:

1. “Classical” HL (CHL)
   • Nodular sclerosis
   • Mixed cellularity
   • Lymphocyte-depleted
   • Lymphocyte-rich
2. Nodular Lymphocyte-Predominant (NLPHL)

In Western countries, CHL accounts for 95% of cases of HL and NLPHL only 5%. Classic HL is characterized by the presence of neoplastic Reed-Sternberg cells in a background of numerous non-neoplastic inflammatory cells. NLPHL lacks Reed-Sternberg cells, but is characterized by the presence of lymphocytic and histiocytic cells termed “popcorn cells”.

The following staging system for HL recognizes the fact that the disease is thought to typically arise in a single lymph node and spread to contiguous lymph nodes with eventual involvement of extranodal sites. The staging system attempts to distinguish patients with localized HL who can be treated with extended field radiation from those who require systemic chemotherapy.

Staging for Hodgkin Lymphoma

Staging for HL is based on the Ann Arbor staging system. Each stage is subdivided into A and B categories. “A” indicates no systemic symptoms are present and “B” indicates the presence of systemic symptoms including unexplained weight loss of more than 10% of body weight, unexplained fevers or drenching night sweats.

Stage I

Involvement of a single lymph node region (I) or localized involvement of a single extralymphatic organ or site (IE).

Stage II

Involvement of 2 or more lymph node regions on the same side of the diaphragm (II) or localized involvement of a single associated extralymphatic organ or site and its regional lymph node(s) with or without involvement of other lymph node regions on the same side of the diaphragm (IIE). The number of lymph node regions involved should be indicated by a subscript (e.g., II2).

Stage III  

Involvement of lymph node regions or structures on both sides of the diaphragm.  These patients are further subdivided as follows:

III-1: disease limited to spleen or upper abdomen
III-2: periaortic or pelvic node involvement

Stage IV

Disseminated (multifocal) involvement of one or more extralymphatic organs, with or without associated lymph node involvement, or isolated extralymphatic organ involvement with distant (nonregional) nodal involvement.

Patients with HL are generally classified into 3 groups: early-stage favorable (stage I–II with no B symptoms or large mediastinal lymphadenopathy), early-stage unfavorable (stage I–II with large mediastinal mass, with or without B symptoms; stage IB–IIB with bulky disease), and advanced-stage disease (stage III–IV).

Patients with nonbulky stage IA or IIA disease are considered to have clinical early stage disease. These patients are candidates for chemotherapy, combined modality therapy, or radiation therapy alone. Patients with obvious stage III or IV disease, bulky disease (defined as a 10-cm mass or mediastinal disease with a transverse diameter exceeding 33% of the transthoracic diameter), or the presence of B symptoms will require combination chemotherapy with or without additional radiation therapy.

HL is highly responsive to conventional chemotherapy, and up to 80% of newly diagnosed patients can be cured with combination chemotherapy and/or radiation therapy. Patients who prove refractory or who relapse after first-line therapy have a significantly worse prognosis. Primary refractory HL is defined as disease regression of less than 50% after 4–6 cycles of anthracycline-containing chemotherapy, disease progression during induction therapy, or progression within 90 days after the completion of first-line treatment.

In patients with relapse, the results of salvage therapy vary depending upon a number of prognostic factors, as follows: the length of the initial remission, stage at recurrence, and the severity of anemia at the time of relapse.  Early and late relapse are defined as less or more than 12 months from the time of remission, respectively. Approximately 70% of patients with late first relapse can be salvaged by autologous HSCT, but not more than 40% with early first relapse. 

Only approximately 25%-35% of patients with primary progressive or poor-risk recurrent HL achieve durable remission after autologous HSCT, with most failures being due to disease progression after transplant. Most relapses after transplant occur within 1–2 years and once relapse occurs post-transplant, median survival is <12 months.

Autologous or myeoablative allogeneic hematopoietic stem-cell transplantation may be considered medically necessary in patients with primary refractory or relapsed Hodgkin lymphoma.

Tandem autologous HSCT may be considered medically necessary:

• in patients with primary refractory HL or
• in patients with relapsed disease with poor risk features who do not attain a complete remission to cytoreductive chemotherapy prior to transplantation (see Policy Guidelines).

Reduced-intensity allogeneic HSCT may be considered medically necessary to treat HL in patients:

• who have failed a prior autologous HSCT used to treat primary refractory or relapsed disease or
• in patients who would otherwise qualify for a myeloablative allogeneic transplant, but would be unable to tolerate a standard myeloablative conditioning regimen (see Policy Guidelines) or
• when insufficient stem cells are collected for an autologous HSCT.

A second autologous stem-cell transplantation for relapsed lymphoma after a prior autologous HSCT is considered investigational.

Other uses of stem-cell transplantation in patients with Hodgkin lymphoma are considered investigational, including, but not limited to, initial therapy for newly diagnosed disease to consolidate a first complete remission.

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.

Some patients for whom a conventional myeloablative allotransplant could be curative may be considered candidates for reduced-intensity conditioning (RIC) allogeneic HSCT. These include those with malignancies that are effectively treated with myeloablative allogeneic transplantation, but whose age (typically older than 55 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy, low Karnofsky Performance Status) preclude use of a standard myeloablative conditioning regimen.

The ideal allogeneic donors are HLA-identical matched siblings. Related donors mismatched at one locus are also considered suitable donors. A matched, unrelated donor identified through the National Marrow Donor Registry is typically the next option considered. Recently, there has been interest in haploidentical donors, typically a parent or a child of the patient, where usually there is sharing of only 3 of the 6 major histocompatibility antigens. The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors.

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.

7/14/2004: Code Reference section completed

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

7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, 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

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

5/21/2007: Policy reviewed, no changes

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

7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).

1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.

04/26/2010: Policy description updated regarding conventional and reduced-intensity conditioning. Policy statement changed to indicate that tandem autologous SCT and reduced-intensity conditioning allogeneic SCT may be considered medically necessary in specific situations. Policy statement also updated to indicate that a second autologous stem-cell transplantation for relapsed lymphoma after a prior autologous hematopoietic stem-cell transplant is considered investigational. Supporting explanations added to the policy guidelines. FEP and State and School Employee 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.

12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary.

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

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

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

Covered Codes

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