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L.8.01.405
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.
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.)
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. No benefits will be provided for any transplant procedure unless prior approval for the transplant is obtained.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
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 reviewed; no changes.
11/30/2012: Policy reviewed; no changes.
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section.
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section.
12/21/2017: Code Reference section updated to add new 2018 CPT code 38222. Revised descriptions for CPT codes 38220 and 38221 effective 01/01/2018.
12/27/2021: Code Reference section updated to make note of deleted ICD-10 procedure codes. Removed deleted CPT code 86822 and deleted HCPCS code G0364.
11/14/2022: Policy reviewed. Policy statement unchanged. Policy Exceptions updated regarding State and School Employee members.
08/21/2023: Policy reviewed; no changes.
12/21/2023: Code Reference section updated to revise the code description for CPT code 96446, effective 01/01/2024.
04/29/2024: Policy Exceptions updated regarding Federal Employee Program subscribers.
08/20/2024: Policy reviewed; no changes.
Blue Cross Blue Shield Association Policy # 8.01.31
This may not be a comprehensive list of procedure codes applicable to this policy.
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 | Diagnostic bone marrow; aspiration(s) | ||
38221 | Bone marrow; biopsy(ies) | ||
38222 | Diagnostic bone marrow; biopsy(ies) and aspiration(s) | ||
38230 | Bone marrow harvesting for transplantation | ||
38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor | ||
38241 | Hematopoietic progenitor cell (HPC); autologous transplantation) | ||
38242 | Allogeneic 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) | ||
86825 | HLA crossmatch, non-cytotoxic (eg, using flow cytometry); first serum sample or dilution | ||
86826 | HLA crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution | ||
96401 | Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic | ||
96402 | Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic | ||
96405 | Chemotherapy administration ; intralesional, up to and including 7 lesions | ||
96406 | Chemotherapy administration; intralesional, more than 7 lesions | ||
96409 | Chemotherapy administration; intravenous, push technique, single or initial substance/drug | ||
96411 | Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) | ||
96413 | Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug | ||
96415 | Chemotherapy administration, intravenous infusion technique; each additional hour, 1 to 8 hours, (List separately in addition to code for primary procedure) | ||
96416 | Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump | ||
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) | ||
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) | ||
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 | ||
96446 | Chemotherapy administration into the peritoneal cavity via implanted port or catheter (Revised 01/01/2024) | ||
96450 | Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture | ||
96521 | Refilling and maintenance of portable pump | ||
96522 | Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) | ||
96523 | Irrigation of implanted venous access device for drug delivery systems | ||
HCPCS | |||
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 | ||
ICD-9 Procedure | ICD-10 Procedure | ||
41.00, 41.01 | Bone marrow transplant code range | 30233G0, 30243G0 | Transfusion of autologous bone marrow into vein (central or peripheral), percutaneous approach |
41.04, 41.07 | Hematopoietic stem cell transplant code range | 30233Y0, 30243Y0 | Transfusion of autologous hematopoietic stem cells into vein (central or peripheral), percutaneous approach |
30233Y0 and 3E03305 | Transfusion of autologous hematopoietic stem cells into peripheral vein, percutaneous approach and introduction of other antineoplastic into peripheral vein, percutaneous approach | ||
30233Y0 and 3E04305 | Transfusion of autologous hematopoietic stem cells into peripheral vein, percutaneous approach and introduction of other antineoplastic into central vein, percutaneous approach | ||
30243Y0 and 3E03305 | Transfusion of autologous hematopoietic stem cells into central vein, percutaneous approach and introduction of other antineoplastic into peripheral vein, percutaneous approach | ||
30243Y0 and 3E04305 | Transfusion of autologous hematopoietic stem cells into central vein, percutaneous approach and introduction of other antineoplastic into peripheral vein, central approach | ||
41.09 | Autologous bone marrow transplant with purging | 30233G0 and 3E04305 | Transfusion of autologous bone marrow into peripheral vein, percutaneous approach and introduction of other antineoplastic into central vein, percutaneous approach |
30233G0 and 3E03305 | Transfusion of autologous bone marrow into peripheral vein, percutaneous approach and introduction of other antineoplastic into peripheral vein, percutaneous approach | ||
30243G0 and 3E04305 | Transfusion of autologous bone marrow into central vein, percutaneous approach and introduction of other antineoplastic into central vein, percutaneous approach | ||
30243G0 and 3E03305 | Transfusion of autologous bone marrow into central vein, percutaneous approach and introduction of other antineoplastic into peripheral vein, percutaneous approach | ||
41.91 | Aspiration of bone marrow from donor for transplant | 079T30Z, 079T3ZZ | Drainage of bone marrow, with or without draining device, percutaneous approach |
07DQ3ZZ, 07DR3ZZ, 07DS3ZZ | Extraction of sternum, iliac, or vertebral bone marrow, percutaneous approach | ||
99.25 | Injection or infusion of cancer chemotherapeutic substance | 3E03305 | Introduction of other antineoplastic into peripheral vein, percutaneous approach |
3E04305 | Introduction of other antineoplastic into central vein, percutaneous approach | ||
99.79 | Other therapeutic apheresis | 6A550ZT, 6A550ZV, 6A551ZT, 6A551ZV | Pheresis of cord blood or hematopoietic stem cells, single or multiple |
ICD-9 Diagnosis | ICD-10 Diagnosis |
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