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 (174.0-174.9, 175.0-175.9, 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 and lab tests performed on family members.  Mass screening may also be included in donor search charges.  This type of screening should be performed in increments of 5 potential donors, in order to avoid screening more potential donors than necessary.

Donor benefits are limited to those not available to the potential donor(s) from any other source.  Payment may be made under the recipient's Mountain State's coverage only when all other sources are exhausted (e.g., the potential donor's insurance coverage, government program funding, etc.)

Mountain State's reimbursement to its contracted facilities (i.e. transplant centers) includes payment for donor searches.  This service is included in the global facility rate for the transplant procedure and is not separately billable to Mountain State or to the member.

If transplant services are performed at a Blue Distinction Centers for Transplant (BDCT) facility, separate payment may be made to the facility for donor search charges.  Donor search charges are not included in the global inpatient rates for these facilities.  The BQCT network consists of transplant centers that meet specific criteria related to provider qualifications and patient outcomes.

Approved facilities can be found at: http://blueweb.bcbs.com/blueweb/Leaf?docld=2209

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 (174.0-174.9, 175.0-175.9, 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.

FEP members must obtain prior approval from their Local Plan prior to a transplant procedure.

FEP covers blood or marrow stem cell transplants, limited to:

Allogenic blood or marrow stem cell transplants for:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous leukemia) leukemia
• Advanced forms of myelodysplastic syndromes
• Advanced Hodgkin's lymphoma
• Advanced neuroblastoma
• Advanced non-Hodgkin's lymphoma
• Chronic myelogenous leukemia
• Infantile malignant osteopetrosis
• Kostmann's syndrome
• Leukocyte adhesion deficiencies
• Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g, Hunter's syndrome, Hurler's syndrome, Sanfilippo's syndrome, Maroteaux-Lamy syndrome variants)
• Myeloproliferative disorders
• Phagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia
• Thalassemia major (homozygous beta-thalassemia)
• X-linked lymphoproliferative syndrome

Autologous blood or marrow stem cell transplants for:

• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin's lymphoma
• Advanced neuroblastoma
• Advanced non-Hodgkin's lymphoma
• Amyloidosis
• Ependymoblastoma
• Ewing's sarcoma
• Medulloblastoma
• Multiple myeloma
• Pineoblastoma
• Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

FEP covers stem cell transplants as part of cancer clinical trials; refer to Mountain State Medical Policy B-41, Clinical Trials for Life Threatening Conditions.

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