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| Section: | Surgery |
| Number: | S-73 |
| Topic: | Bone Marrow, Peripheral Blood, and Umbilical Cord Stem Cell Transplantation |
| Effective Date: | August 1, 2005 |
| Issued Date: | August 1, 2005 |
| Date Last Reviewed: | 06/2005 |
Indications and Limitations of Coverage
Bone Marrow Transplantation Payment may be made for the harvesting (38230) of homologous bone marrow and the infusion/transplant (38240) of the bone marrow as distinct eligible services when medically necessary for treatment, regardless of the indication for which it is performed. Autologous (Self) Payment may be made for the harvesting (38230) of autologous bone marrow and the reinfusion (38241) of the bone marrow as distinct eligible services. Bone marrow donor search charges generally include registry fees, lab tests performed on family members and those prescribed by a physician. Mass screening and testing not prescribed by a physician may also be included in donor search charges. Medically necessary services provided for the diagnosis, or the direct care and treatment of the member's condition, illness, or injury are contractually covered. Registry fees are generally not covered because there is no physician service rendered for the direct care or treatment of the member. Liability for potential donor testing lies with the potential donor's health plan. A potential donor is asymptomatic. Therefore, testing for potential donors is considered screening. Screening services are not covered except for those groups identified in benefits. Peripheral Stem Cell Transplantation The transplantation of peripheral stem cells is also used to restore marrow function in a patient who has received marrow ablative therapy. The stem cells are harvested from peripheral blood prior to high dose chemotherapy by multiple leukapheresis procedures. Peripheral stem cell transplantation (allogeneic or autologous) is generally a covered service when medically necessary for treatment. However, as compared with maintenance chemotherapy in conventional doses, high-dose chemotherapy with autologous peripheral stem cell transplantation soon after the induction of a complete or partial remission with conventional-dose chemotherapy does not improve survival in women with metastatic breast cancer (174, 175, 198.81). Autologous peripheral stem cell transplantation in these cases is considered experimental/investigational and not eligible for payment. A participating, preferred, or network provider can bill the member for the denied service. Payment may be made for the harvesting of the peripheral stem cells (38205, 38206) and the reinfusion/infusion of the peripheral stem cells (38240, 38241) as distinct eligible services Umbilical Cord Stem Cell Transplantation The transplantation of umbilical cord stem cells may be used to support high dose chemotherapy and to treat patients with primary bone marrow disease. The cord stem cells are harvested by neonatologists or obstetricians at the time of delivery. Payment may be made for the harvesting of homologous umbilical cord stem cells (S2140) and the reinfusion of the homologous umbilical cord stem cells (S2142) as distinct eligible services. The harvesting of autologous umbilical cord stem cells (38999) and the reinfusion of autologous umbilical cord stem cells (38999) should be denied as not covered on the basis that the harvesting would be performed and the cells stored without an established diagnosis for the potential use during the patient's lifetime.
Description High dose chemotherapy (HDC) with stem cell transplantation is used in the treatment of malignant and non-malignant diseases. HDC involves the administration of cytotoxic agents at doses several times greater than the standard therapeutic dose. The most severe adverse side effect of HDC is marrow ablation. Therefore, HDC is accompanied by a reinfusion of stem cells in order to repopulate the bone marrow. In the treatment of marrow-based diseases, the therapeutic intent is marrow ablation, with marrow reconstitution using donor stem cells. Stem cells are primitive cells capable of replication and formation of mature blood cells. Stem cells can be harvested from three sources: bone marrow, peripheral blood, and umbilical cords. The appropriate stem cell source for a particular patient depends upon his or her disease, treatment history, and the availability of a donor. |
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| 38205 | 38206 | 38230 | 38240 | 38241 | S2140 |
| S2142 |
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| FEP benefits are available for the following human organ/tissue transplant procedures as stated in the Service Benefit Plan brochure.
Allogeneic bone marrow transplant and allogeneic cord blood stem cell transplant (from related or unrelated donors) for:
Allogeneic bone marrow transplant, allogeneic cord blood stem cell transplant (from related or unrelated donors) and allogeneic peripheral blood stem cell transplant for:
Autologous bone marrow (autologous stem cell support) and autologous peripheral stem cell support
Coverage for allogeneic bone marrow transplants for the diagnosis of multiple myeloma (203.0) and coverage for autologous bone marrow transplants (ABMT) and peripheral stem cell transplants for the diagnoses of breast cancer (173.5, 174, 175, 198.2, 198.81, 233.0), multiple myeloma (203.0), and epithelial ovarian cancer (183-183.0, 198.6), is available for services rendered on or after September 23, 1994. Benefits are also available for transportation (S9992), lodging (S9994, S9976), and meals (S9996, S9977) for the clinical trial participant and one caregiver. In addition, prior approval of benefits for these services should be referred to the Medical and Quality Management Department of the national Blue Cross Blue Shield Association. All other requests for prior approval of benefits for allogeneic and autologous bone marrow and peripheral stem cell transplants will continue to be reviewed by the Plan. Bone Marrow Donor Search ChargesFEP benefits are available for any related registry charges from which the bone marrow of an unrelated donor is received if a suitable sibling donor cannot be found. Any registry charges other than the one from which the bone marrow is received are not covered. All charges incurred as a result of the testing/typing are considered to be expenses of the recipient to the extent the potential donor has no other coverage. |
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PRN References |
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Conventional-Dose Chemotherapy Compared with High-Dose Chemotherapy Plus Autologous Hematopoietic Stem-Cell Transplantation for Metastatic Breast Cancer, New England Journal of Medicine, Vol. 342, No. 15, 4/13/2000 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
