Bone Marrow Transplantation

Homologous/Allogeneic (Donor)
Homologous/allogeneic bone marrow transplantation is a procedure in which a portion of a healthy donor's bone marrow is obtained and prepared for intravenous infusion to restore normal marrow function in recipients having an inherited or acquired marrow deficiency or defect or for patients who have had marrow ablative therapy (high dose chemotherapy).

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)
Autologous bone marrow transplantation (ABMT) is a technique for restoring bone marrow stem cells using the patient's own previously purified and stored marrow. Autologous bone marrow transplantation is generally a covered service when medically necessary for treatment. However, as compared with maintenance chemotherapy in conventional doses, high-dose chemotherapy with autologous bone marrow 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 bone marrow 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 (38230) of autologous bone marrow and the reinfusion (38241) of the bone marrow as distinct eligible services.

Bone Marrow Donor Search Charges
Allogeneic bone marrow transplants may be performed using marrow obtained from an individual who is not related to the patient. The donor can be located through a Bone Marrow Donor Search Registry. Two such organizations are the American Registry and the National Registry. A patient may require one to an indefinite number of searches to find an acceptable donor, depending upon blood type and availability. The patient's family members are usually tested first to determine if there is an available match. If no available match exists, a bone marrow donor search is performed.

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.

NOTE:

Charges for prophylactic blood, peripheral blood, umbilical cord blood and bone marrow storage are not eligible for payment. See Medical Policy Bulletin Z-46 for additional information on blood and bone marrow storage.

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.

NOTE:

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.

Allogeneic bone marrow transplant and allogeneic cord blood stem cell transplant (from related or unrelated donors) for:

1. Advanced neuroblastoma
2. Infantile malignant osteopetrosis: 756.52
3. Severe combined immunodeficiency: 279.2
4. Wiskott-Aldrich syndrome: 279.12
5. Mucopolysaccharidosis (e.g., Hunter, Hurler's, Sanfilippo, Maroteaux-Lamy variants); Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy: 277.5, 272.7, 330.0
6. Severe or very severe aplastic anemia: 284
7. Thalassemia major (homozygous beta-thalassemia): 282.41, 282.42, 282.49
8. Sickle cell anemia 282.60, 282.64, 282.68

Allogeneic bone marrow transplant, allogeneic cord blood stem cell transplant (from related or unrelated donors) and allogeneic peripheral blood stem cell transplant for:

1. Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia: 204.0, 205.0, 206.0, 207.0, 208.0
2. Advanced Hodgkin's lymphoma: 201
3. Advanced Non-Hodgkin's lymphoma: 200-202
4. Chronic myelogenous leukemia: 205.1-205.11
5. Advanced forms of myelodysplastic syndromes: 238.7

Autologous bone marrow (autologous stem cell support) and autologous peripheral stem cell support

1. Acute lymphocytic or non-lymphocytic leukemia: 204.0, 205.0, 206.0, 207.0, 208.0
2. Advanced Hodgkin's lymphoma: 201
3. Advanced Non-Hodgkin's lymphoma: 200, 202
4. Advanced neuroblastoma
5. Testicular, mediastinal, retroperitoneal and ovarian germ cell tumors
6. Breast cancer: 173.5, 174, 175, 198.2, 198.81, 233-233.0
7. Multiple myeloma: 203-203.01
8. Epithelial ovarian cancer: 183-183.0, 198.6
9. Amyloidosis (277.3)

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.

FEP 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.

PRN References

02/1993, 06/1994, Autologous bone marrow transplantation (ABMT) for breast cancer, codes and reporting of
12/1993, Autologous bone marrow transplantation (ABMT) for breast cancer, policy guidelines
12/1993, Homologous/allogeneic bone marrow transplantation, policy guidelines
01/1995, Homologous/allogeneic bone marrow transplantation, codes and reimbursement for
06/1994, Peripheral stem cell transplantation, reporting of
10/1995, Peripheral stem cell transplantation, codes and reporting of
02/1996, Peripheral stem cell transplantation, codes for
10/1995, Umbilical cord stem cell transplantation, codes and reporting of
6/2000, Coverage withdrawn for autologous stem cell transplantation for the treatment of metastatic breast cancer

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