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A.8.01.23
The use of hematopoietic cell transplantation (HCT) has been investigated to treat individuals with epithelial ovarian cancer. Hematopoietic stem cells are infused to restore bone marrow function after cytotoxic doses of chemotherapeutic agents with or without whole body radiotherapy. Stem cell transplantation to treat germ cell tumors of the ovary is considered separately in the Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors medical policy.
Epithelial Ovarian Cancer
Several 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 for 2024 were estimated at 19,680 and 12,740, respectively. Most ovarian cancer patients present with widespread disease, and the National Cancer Institute Surveillance, Epidemiology and Results Program reported a 50.9% 5-year survival for all cases between 2014 and 2020.
TreatmentCurrent management of advanced epithelial ovarian cancer is cytoreductive surgery with chemotherapy. Approximately 75% of patients present with International Federation of Gynecology and Obstetrics stage III to IV ovarian cancer and are treated with paclitaxel plus a platinum analogue (e.g. cisplatin), the preferred regimen for newly diagnosed advanced disease. Use of platinum and taxanes has improved progression-free survival and overall survival in advanced disease to between 16 and 21 months and 32 and 57 months, respectively. However, cancer recurs in most women, and they die of the disease because chemotherapy drug resistance leads to uncontrolled cancer growth.
Hematopoietic Cell Transplantation
Hematopoietic cell transplantation (HCT) is a procedure in which hematopoietic stem cells are infused to restore bone marrow function in cancer patients who receive bone-marrow-toxic doses of drugs with or without whole body radiotherapy. Bone marrow stem cells may be obtained from the transplant recipient (autologous HCT) or 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. Cord blood transplantation is discussed in detail in the Placental and Umbilical Cord Blood as a Source of Stem Cells policy.
HCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults is largely experimental.
The U.S. Food and Drug Administration (FDA) regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under Code of Federal Regulation (CFR), title 21, parts 1270 and 1271. Hematopoietic stem cells are included in these regulations.
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 and allogeneic hematopoietic cell transplantation are considered investigational to treat advanced stage epithelial ovarian cancer.
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: 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.
03/10/2014: Policy reviewed; description updated. Policy statement unchanged.
12/19/2014: Policy reviewed; description updated. Policy statement unchanged.
08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446.
03/17/2016: Policy description updated regarding estimated data for 2016 and FDA regulations. Policy statement unchanged. Investigative definition updated in policy guidelines section.
05/25/2016: Policy number A.8.01.23 added.
09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4.
01/31/2017: Policy updated to change "hematopoietic stem-cell transplantation" to "hematopoietic cell transplantation." Policy description updated to add section heading. Policy statement unchanged.
12/21/2017: Code Reference section updated to add new 2018 CPT code 38222. Revised descriptions for CPT 38220 and 38221 effective 01/01/2018. Removed deleted ICD-10 procedure codes 30230G1, 30233G1, 30240G1, 30243G1, 30230Y1, 30233Y1, 30240Y1, and 30243Y1.
02/08/2018: Policy description updated regarding 2017 data for ovarian cancer. Policy statement updated to add "advanced stage" to epithelial ovarian cancer.
03/11/2019: Policy description updated to remove information regarding HCT for epithelial ovarian cancer for which limited data exists. Policy statement unchanged. Policy Exceptions updated regarding State and School Employee members. Code Reference section updated to remove deleted CPT code 86822 and HCPCS code G0364.
09/27/2019: Code Reference section updated to add new ICD-10 procedure codes 30230U2, 30233U2, 30240U2, 30243U2, 30230U3, 30233U3, 30240U3, 30243U3, 30230U4, 30233U4, 30240U4, and 30243U4, effective 10/01/2019.
02/21/2020: Policy description updated. Policy statement unchanged.
03/05/2021: Policy description updated regarding 2020 data for ovarian cancer. Policy statement unchanged.
12/27/2021: Code Reference section updated to make note of deleted ICD-10 procedure codes.
02/16/2022: Policy description updated regarding new data for epithelial ovarian cancer in the United States. Policy statement unchanged.
02/23/2023: Policy reviewed. Policy statement unchanged. Code Reference section updated to remove deleted ICD-10 procedure codes 30230G0, 30240G0, 30230G2, 30240G2, 30230G3, 30240G3, 30230G4, 30240G4, 30230U2, 30240U2, 30230U3, 30240U3, 30230U4, 30240U4, 30230Y2, 30240Y2, 30230Y3, 30240Y3, 30230Y4, 30240Y4, 30230Y0, and 30240Y0.
12/21/2023: Code Reference section updated to revise the code description for CPT code 96446, effective 01/01/2024.
02/26/2024: Policy description updated regarding new data for ovarian cancer. Policy statement unchanged.
04/07/2025: Policy description updated regarding new data for ovarian cancer. Policy statement unchanged.
Blue Cross Blue Shield Association Policy # 8.01.23
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 | Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); first serum sample or dilution | ||
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) | ||
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 | ||
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 - To report antineoplastic drugs, see code range J9000-J9999 in the HCPCS Level II manual. | |||
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 | ||
S2140 | Cord blood harvesting for transplantation, allogeneic | ||
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | ||
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 | ||
41.01, 41.02, 41.03 | Bone marrow transplant code range | 30233G0, 30243G0 | Transfusion of autologous bone marrow into vein (peripheral or central), percutaneous approach |
30233G2, 30243G2 | Transfusion of allogeneic related bone marrow into vein (peripheral or central), percutaneous approach | ||
30233G3, 30243G3 | Transfusion of allogeneic unrelated bone marrow into vein (peripheral or central), percutaneous approach | ||
30233G4, 30243G4 | Transfusion of allogeneic unspecified bone marrow into vein (peripheral or central), percutaneous approach | ||
30233U2, 30243U2 | Transfusion of allogeneic related T-cell depleted hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233U3, 30243U3 | Transfusion of allogeneic unrelated T-cell depleted hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233U4, 30243U4 | Transfusion of allogeneic unspecified T-cell depleted hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233Y2, 30243Y2 | Transfusion of allogeneic related hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233Y3, 30243Y3 | Transfusion of allogeneic unrelated hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
30233Y4, 30243Y4 | Transfusion of allogeneic unspecified hematopoietic stem cells into vein (peripheral or central), percutaneous approach | ||
41.04, 41.05, 41.07, 41.08 | Hematopoietic stem cell transplant code range | 30233Y0, 30243Y0 | Transfusion of autologous or nonautologous hematopoietic stem cells into vein (peripheral or central), percutaneous approach |
41.09 | Autologous bone marrow transplant with purging | 30233G0, 30243G0 | (See description above) |
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 |
99.79 | Other apheresis (harvest) of stem cells | 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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