Medical Policy

 

Subject: Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Document #: TRANS.00031 Publish Date:    06/06/2018
Status: Reviewed Last Review Date:    05/03/2018

Description/Scope

This document addresses hematopoietic stem cell transplantation in the treatment of the following conditions:

Note: For additional stem cell transplant information and criteria, see the applicable document(s):

Position Statement

Autoimmune Diseases

Investigational and Not Medically Necessary:

An autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, single or planned tandem is considered investigational and not medically necessary as a treatment of autoimmune diseases including, but not limited to:

Epithelial Ovarian Cancer

Investigational and Not Medically Necessary:

An autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, single or planned tandem is considered investigational and not medically necessary as a treatment of epithelial ovarian cancer.

Breast Cancer

Investigational and Not Medically Necessary:

An autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, single or planned tandem is considered investigational and not medically necessary as a treatment of breast cancer.

Malignant Astrocytomas and Gliomas

Investigational and Not Medically Necessary:

An autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, single or planned tandem is considered investigational and not medically necessary as a treatment of malignant astrocytomas and gliomas, including both glioblastoma multiforme and oligodendroglioma.

Other Miscellaneous Solid Tumors in Adults

Investigational and Not Medically Necessary:

An autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, single or planned tandem is considered investigational and not medically necessary as a treatment of adult miscellaneous solid tumors, including but not limited to the following:

Rationale

Autoimmune Diseases

The use of high dose chemotherapy with autologous stem cell transplantation has demonstrated improved outcomes for specific oncologic indications such as leukemia and lymphoma. Based on the experiences in these historic applications, the use of autologous and allogeneic stem cell transplantations continues to be studied in other oncologic and non-oncologic indications such as autoimmune diseases and miscellaneous solid tumors. However, in a position statement from a National Institute of Allergy and Infectious Diseases and National Cancer Institute-Sponsored International Workshop on the “Feasibility of Allogeneic Hematopoietic Stem Cell Transplantation for Autoimmune Diseases”, the authors concluded that “Although safer allogeneic transplantation strategies have become available, experience is currently insufficient to allow reliable extrapolation of data on safety and risks from patients with malignancies to patients with autoimmune diseases” (Griffith, 2005).

Currently, there are multiple ongoing clinical trials using autologous and allogeneic stem cell transplants following high dose immunotherapies for the treatment of autoimmune diseases. Burt and colleagues (2006) described lymphoablation or the removal of “autoreactive lymphocytes” through the process of autologous stem cell transplantation to promote the generation of new self-tolerant lymphocytes. Examples of autoimmune disorders being studied in this manner include multiple sclerosis (MS), systemic scleroderma (SSc; that is, scleroderma), rheumatoid arthritis (RA), Crohn’s disease and lupus. These authors have identified the need for further research with randomized controlled trials to verify the benefit and safety of this therapy.

Burt and colleagues (2009) recently reported a retrospective case series of 21 subjects with relapsing-remitting multiple sclerosis who had not previously responded to conventional treatment with interferon beta and received autologous non-myeloablative hematopoietic stem cell transplantation (HSCT) following conditioning with cyclophosphamide and either alemtuzumab or antithymocyte globulin. Initial study results 3 years post-transplantation reported progression-free survival (PFS) and reversal of neurologic disability. Of the 21 subjects transplanted, 17 (81%) increased their score by at least one point on the Kutzke expanded disability status scale (EDSS). Relapse was reported in 5 individuals (24%), but after further immunosuppressive therapy remission was achieved. The author reported a mean follow-up of 37 months (range 24-48 months) at which time all participants were free from progression (no deterioration in EDSS score) and 16 were free of relapse. Significant improvements were noted in neurological disability scores (p<0.0001) and quality of life as measured with the short form-36 (SF-36) questionnaire.

Shevchenko (2008) reported a prospective, multi-center Russian case series of 50 subjects who received high-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (auto-HSCT) as a treatment alternative for various forms (secondary progressive [n=27], primary progressive [n=11], relapsing-remitting [n=11], and progressive relapsing [n=1]) of multiple sclerosis. Median disease duration prior to the trial was 7.5 years. Study participants were conditioned with BCNU, etoposide, cytarabine, and melphalan (BEAM) followed by stem cell transplantation. In vivo T-cell depletion was achieved through infusion of anti-thymocyte globulin. The results were pooled for three different strategies of HDIT + auto-HSCT: “early” transplantation (n=6; EDSS 1.5-3.0), “conventional” transplantation (n=37; EDSS 3.5-6.5) and “salvage/late” transplantation (n=4; EDSS 7.0-8.0).

Results were reported for 45 individuals. Twenty-eight subjects achieved an objective improvement in neurologic symptoms, defined as at least a 0.5 point decrease in the EDSS score from baseline at 6 months. Estimated progression-free survival at 6 years was 72% and no active, new, or enlarging lesions were seen on brain MRI in individuals without disease progression. One participant died of acute promyelocytic leukemia 3 years after HDIT + auto-HSCT. This study was limited by the lack of an active comparator group and a heterogeneous population mix. In addition, the number of subjects in groups with different treatment strategies was quite small and mean follow-up was only 19 months with less than half of the participants observed for more than 3 years. Although early clinical studies are promising, a randomized, comparative trial is needed to establish the efficacy and safety of HDIT with auto-HSCT in the treatment of multiple sclerosis.

A systematic review published by Reston and colleagues (2011) evaluated the safety and efficacy of autologous HSCT in participants with progressive MS refractive to conventional treatment. A total of 10 full-text articles were reviewed, and 8 case series with 161 enrolled participants and median 2 year follow-up were included, meeting the inclusion criteria for primary outcome of progression-free survival. An additional 6 studies were included for a summary of mortality and morbidity. Analysis from the eight case series found there was substantial heterogeneity across studies. Secondary progressive MS was reported in 77% of participants, but studies also included those with primary progressive, progressive-relapsing, and relapse-remitting disease. The studies used varied conditioning regimens prior to HSCT. Five of the studies used intermediate-intensity regimens and the remaining three used high-intensity regimens. All studies were rated as moderate quality. Among a total of 14 studies, 13 were case series; of which seven treatment-related deaths were reported. Six non-treatment related deaths were reported, and five of these were associated with disease progression:

The estimated rate of long-term progressive-free survival of patients receiving intermediate-intensity conditioning regimens was 79.4% (95% CI: 69.9-86.5%) with a median follow-up of 39 months, while the estimate for the patients receiving high-intensity regimens was 44.6% (95% CI: 26.5-64.5%) at a median follow-up at 24 months.

Muraro and colleagues (2017) reported long term results (median 6.6 years) from a multicenter, observational retrospective cohort study. Data was obtained for 281 participants with predominantly progressive forms of MS (n=218; 78%), with median Expanded Disability Status Scale (EDSS) score of 6.5 (range 1.5-9) treated with autologous HSCT (AHSCT). Within the first 100 days of AHSCT there were 8 (2.8%; 95% CI, 1.0%-4.9%) deaths reported and considered transplant-related mortality. “The 5-year probability of progression-free survival as assessed by the EDSS score was 46 (95% CI, 42%-54%), and overall survival was 93% (95% CI, 89%-96%) at 5 years.” The summary the authors conclude:

In this observational study of patients with MS treated with AHSCT, almost half of them remained free from neurological progression for 5 years after transplant. Younger age, relapsing form of MS, fewer prior immunotherapies, and lower baseline Expanded Disability Status Scale EDSS score were factors associated with better outcomes. The results support the rationale for further randomized clinical trial of AHSCT for the treatment of MS.

A case series by Nash and colleagues (2017) reported findings of a phase II clinical trial of high-dose immunosuppression therapy (HDIT) and autologous HCT for participants with relapsing-remitting multiple sclerosis who experienced relapses with disability progression. Of the 25 participants evaluated 24 underwent HDIT/HCT with median follow-up of 62 months. The event free survival was 69.2% (CI 50.2-82.1), “Progression free survival, clinical relapse-free survival and MRI activity-free survival were 91.3% (90% CI 74.7-97.2%), 86.9% (90% CI 69.5%-94.7%), and 86.3% (90% CI 68.1%-94.5%), respectively.” There were no neurological treatment-related adverse events reported, there were 3 deaths due to disease progression, no deaths related to transplantation. The authors concluded that research in “prospective clinical trials comparing HDIT/HCT to other approaches are needed.”

Evidence at this point is insufficient to establish the long-term safety and durable efficacy of this therapy in the treatment of MS. Further study in randomized, controlled trials is needed to establish a role for this treatment in halting the progression of multiple sclerosis. At this time there is one phase III randomized trial (Stem Cell Therapy for Patients with Multiple Sclerosis Failing Interferon-A Randomized study, NCT00273364), designed to study the effect of autologous peripheral blood HSCT in individuals with relapsing MS versus U.S. Food and Drug Administration approved standard of care. Estimated enrollment 110 participants and estimated study completion date is December 2018 (Northwestern University, 2016).

Nash (2007) reported a phase 2 single arm study using high dose immunosuppressive therapy (HDIT) and autologous hematopoietic cell transplant (HCT) to treat 34 individuals with diffuse cutaneous systemic sclerosis (SSc). HDIT included total body irradiation (800 cGy) with lung shielding, cyclophosphamide (120 mg/kg), and equine antithymocyte globulin (90 mg/kg). Seventeen of 27 (63%) evaluable subjects who survived at least 1 year after HDIT had sustained responses at a median follow-up of 4 (range, 1 to 8) years. There was a major improvement in skin (modified Rodnan skin score, -22.08; p<0.001) and overall function (modified Health Assessment Questionnaire Disability Index, -1.03; p<0.001) at final evaluation. Biopsies confirmed a statistically significant decrease of dermal fibrosis compared with baseline (p<0.001). Lung, heart, and kidney function, in general, remained clinically stable. However, there were 12 deaths during the study and 8 of 27 participants had transplant–related mortality. The estimated progression-free survival was 64% at 5 years. The authors concluded that HDIT and autologous HCT for SSc should be evaluated in a randomized clinical trial.

Vonk (2008) reported a case series of 26 subjects with severe, diffuse cutaneous SSc treated with autologous stem cell transplant following HDIT. In this study, peripheral blood stem cells were collected using cyclophosphamide (4 g/m2) and rHu G-CSF (5 to 10 microg/kg/day) and were reinfused after positive CD34+ selection. For conditioning, cyclophosphamide 200 mg/kg was used. After a median follow-up of 5.3 (1-7.5) years, 81% (n=21/26) of the participants demonstrated a clinically beneficial response. The Kaplan-Meier estimated survival at 5 years was 96.2% (95% confidence interval [CI], 89-100%) and at 7 years 84.8% (95% CI, 70.2-100%) and event-free survival, defined as survival without mortality, relapse or progression of SSc resulting in major organ dysfunction was 64.3% (95% CI, 47.9-86%) at 5 years and 57.1% (95% CI, 39.3-83%) at 7 years. The results of this study are promising, but its small size and uncontrolled design limit the conclusions which can be drawn. Further study with larger phase III, randomized controlled trials are needed.

Burt and colleagues (2011) reported on a non-randomized phase II study evaluating HSCT effectiveness in the treatment of diffuse SSc. Participants were randomly allocated via computer sequencing, 10 participants to the HSCT (cyclophosphamide 200mg/kg IV in combination with rabbit antithymocyte globulin 6.5mg/kg IV) group and 9 participants to cyclophosphamide group (1.0 g/m2 IV once every 6 months). At 1 year the primary outcome was measured as decrease of greater than 25 % in subjects presenting at enrollment with greater than 14 modified Rodnan skin scores (mRSS) or an increase in the forced vital capacity by 10%. The primary outcome results at 1 year reported with the mean (mRSS) increased in the control group (19 to 22) and a decrease in the transplant group (28 to 15) 1 year post treatment. The vital capacity results at 1 year in subjects “undergoing HSCT compared with controls, the rate of change from pretreatment forced vital capacity was 34% compared with -10% at 6 months (p=0.002) and 15% compared with -9% at 12 months (p=0.006).” Eight of 9 subjects in the control group with disease progression reported at 1 year were able to switch over to the HSCT protocol for additional treatment. The study provides promising initial findings with use of non-myeloablative autologous HSCT in SSc, although larger studies are needed with long term follow-up to demonstrate the benefits of treatment.

A number of clinical trials studying the efficacy and safety of HDIT with HCT in various autoimmune disorders are in progress (Clinical Trials.gov). One study underway, the Scleroderma: Cyclophosphamide or Transplantation Trial (SCOT), is a randomized, open label, active control trial comparing the efficacy and safety of high-dose immunosuppressive therapy (HDIT) followed by HCT and high-dose pulse IV cyclophosphamide. This is a multi-center study with enrollment originally designed for 226 participants, with event-free survival as the preliminary endpoint. As a result of low accrual, the study was amended to broaden entry criteria, then ultimately to reduce the sample size by changing the primary endpoint to global rank composite, a design with an estimated enrollment of 114 subjects. The study enrolled 75 participants with severe scleroderma including participants with internal organ involvement, 36 to the HCT group and 39 to the cyclophosphamide group.

In 2018, Sullivan and colleagues assessed SCOT trial results at 54 to 72 months in the intent-to-treat population. At that point, 205 subjects had been screened and 73 were randomized. Thirty three of 37 randomized subjects received myeloablative autologous transplant. Thirty two of the 36 subjects randomized to receive 12 months of cyclophosphamide received that treatment. The study used a unique global score as the primary outcome, making comparison to other studies of scleroderma treatment difficult. Sixty seven percent of pairwise comparisons between transplant and cyclophosphamide recipients showed a higher global score for the transplant recipient. There were a total of 21 reported deaths, 7 in the transplant group (n=3 did not undergo transplantation; n=2 died of treatment-related causes; 2 had prior respiratory, renal or cardiac failure) and 14 in the cyclophosphamide group (n=3 received 5 or less doses; n=7 had respiratory, renal or cardiac event; none attributed directly to treatment). Estimated event free survival at 72 months, 74% for transplant group and 47 % for cyclophosphamide group and overall survival 86% versus 51% (P=0.03 and 0.02, respectively). In a letter-to-the-editor, Shenoy and Sreenath note that the event-free survival benefit for the transplanted group in the SCOT trial did not occur until the second year after initiation of treatment, one year after the cyclophosphamide group stopped treatment. The very low transplant-related mortality may not be generalizable to treatment at other transplant centers.

Mahdi-Rodgers (2009) reported results from a small trial of participants with chronic acquired demyelinated neuropathy (CADP) refractory to other treatments who underwent autologous PBSCT. In the study, a total of 6 participants underwent transplantation, 3 with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), 2 with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) and 1 with an IgM paraprotein and antibodies to nerve. Four of the 6 participants developed neutropenic septicemia and pneumonia. The authors concluded that “the literature and our limited experience suggest that autologous PBSCT produces improvement in some patients with CADP but carries a risk of serious side effects and relapse after 1 or 2 years.”

Miscellaneous Solid Tumors

Solid tumors are a heterogeneous group of neoplasms involving many different body systems. These tumors have usually demonstrated chemosensitivity to a variety of antineoplastic agents. Based on the previous responses to standard chemotherapeutic treatment regimens, the use of chemotherapy in higher doses with hematopoietic stem cell transplantation to achieve improved responses was proposed. However, there have not been large randomized trials to demonstrate improved responses and outcomes with the use of high dose chemotherapy with HSC.

At this time, there is not sufficient evidence in the peer-reviewed medical literature, in terms of long-term safety and efficacy, to support the use of bone marrow/stem cell transplantation, for the indications listed as investigational and not medically necessary. The majority of studies performed to date are either case reports, retrospective reviews, or phase II studies with short follow-up, no control groups and heterogeneous populations. There have been no large-scale prospective trials that have demonstrated improved outcomes. There are ongoing clinical trials studying the use, safety and effectiveness of stem cell transplant as a treatment for these investigational indications.

Background/Overview

Hematopoietic stem cell transplantation is a process which includes mobilization, harvesting, and transplant of stem cells after the administration of high dose chemotherapy (HDC) and/or radiotherapy. High-dose chemotherapy involves the administration of cytotoxic or immunosuppressive agents using doses greater than the standard therapeutic dose. In some cases, whole body or localized radiotherapy is also given and is included in the term HDC when applicable. The rationale for HDC is that many cytotoxic agents act according to a steep dose-response curve. Thus, small increments in dosage will result in relatively large increases in tumor cell kill. Increasing the dosage also increases the incidence and severity of adverse effects related primarily to bone marrow ablation (e.g., opportunistic infections, hemorrhage, or organ failure). Bone marrow ablation is the most significant side effect of HDC. As a result, HDC is accompanied by a re-infusion of hematopoietic stem cells, which are primitive cells capable of replication and formation into mature blood cells, in order to repopulate the marrow. The potential donors of stem cells include:

  1. Autologous - Stem cells can be harvested from an individual’s own bone marrow or peripheral blood
  2. Allogeneic - Stem cells harvested from a histocompatible donor

Donor stem cells, either autologous or allogeneic, can be collected from either the bone marrow or the peripheral blood. Stem cells may be harvested from the peripheral blood using a pheresis procedure. To increase the number of stem cells in the peripheral circulation, donors may be pretreated with a course of chemotherapy or hematopoietic growth factors, or both.

In addition, blood harvested from the umbilical cord and placenta shortly after delivery of neonates contains stem and progenitor cells. Although cord blood is an allogeneic source, these stem cells are antigenically “naïve” and thus, are associated with a lower incidence of rejection or graft versus host disease.

The most appropriate stem cell source for a particular individual depends upon his or her disease, treatment history, and the availability of a compatible donor. The most appropriate source of stem cells for each individual must balance the risks of graft failure and re-infusion of malignant cells in autologous procedures, the risks of graft rejection, and graft versus host disease in allogeneic procedures.

While some hematopoietic stem cell transplant protocols can be administered on an outpatient basis, an inpatient stay may be required.

While the intensity of the regimens used for conditioning in conventional HDC varies, collectively they have been termed “myeloablative.” Several less intense conditioning regimens have been developed and rely more on immunosuppression than cytotoxic effects to permit engraftment of donor cells. These regimens, collectively termed “non-myeloablative,” also vary in intensity with substantial overlap between the ranges for “myeloablative” and “non-myeloablative” regimens. Studies have shown that donor allogeneic stem cells can engraft in recipients using less-intensive conditioning regimens that are sufficiently immunosuppressive to permit graft-host tolerance. This manifests as a stable mixed donor-host hematopoietic chimerism. Once chimerism has developed, a further infusion of donor leukocytes may be given to eradicate malignant cells by inducing a graft vs. tumor effect. Non-myeloablative allogeneic transplants also referred to as “mini-transplant, transplant lite or reduced intensity conditioning,” are thought to be potentially as effective as conventional HDC followed by an allogeneic stem cell transplantation (AlloBMT), but with decreased morbidity and mortality related to the less intense non-myeloablative chemotherapy conditioning regimen. Consequently, for individuals with malignancies who are eligible for conventional HDC/AlloBMT, conditioning with milder, non-myeloablative regimens (NM-AlloBMT) represents a technical modification of an established procedure.

Tandem high-dose or non-myeloablative chemotherapy with autologous and/or allogeneic stem cell support is the planned administration of more than one cycle of high-dose chemotherapy, alone or with total body irradiation, each of which is followed by re-infusion of stem cells. Despite treatment with high-dose chemotherapy, many individuals with advanced malignancies eventually relapse, indicating the presence of residual neoplastic cells. The hypothesis is that eradication of residual tumor cells can be achieved using multiple cycles of myeloablative or non-myeloablative chemotherapy with stem cell support.

Autoimmune diseases are the result of an inappropriate activation of humoral or cellular immune responses against the individual’s own cells or tissues. It is not completely understood why the immune system becomes intolerant to its host. Available evidence implicates a combination of genetic, hormonal, and/or environmental factors. Several common conditions that are believed to involve autoimmunity include rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), multiple sclerosis (MS), pemphigus, juvenile RA and systemic sclerosis (scleroderma). In general, these diseases can be controlled with standard anti-inflammatory, anti-malarial, or immunosuppressive medications in conjunction with supportive care. In a small proportion of individuals, the disease is refractory to treatment and can become severe, debilitating, and organ or life threatening. This most commonly occurs with some forms of MS, scleroderma and amyotrophic lateral sclerosis (Lou Gehrig’s disease). Individuals with these more severe forms of autoimmune disease or individuals who do not respond to medical treatment have been investigated as potential candidates for high-dose immunosuppressive therapy followed by hematopoietic stem cell transplantation (HSCT).

Epithelial ovarian cancer is a clonal disease of unknown cause that arises from a single cell. Epidemiologic studies have not identified any consistent predisposing factors. Caucasian race, nulligravidity, late age of menopause, prolonged intervals of ovulation, and family history are individual characteristics that have been found to be associated with increased risk. Some evidence exists to indicate that ovarian cancers are more prevalent in some families than in the general population. These families also demonstrate a higher prevalence of breast cancer. Familial or hereditary patterns account for less than 5% of epithelial ovarian cancer cases and generally occur in women approximately 10 years earlier than the overall mean age of onset. The precise risk of developing epithelial ovarian cancer in women with a strong family history is undetermined but is believed to be dependent upon the number of first- and/or second-degree relatives affected. In recent years, the option of prophylactic oophorectomy in individuals from families with strong familial histories of ovarian cancer has emerged. This measure, however, does not completely eliminate the possibility of disease since the entire coelomic epithelium is believed to be at risk.

Breast cancer is malignant abnormal cell growth in the breast. Cancer cells may spread to other areas of the body (called metastasis). Fibrocystic changes (for example, formation of cysts, scar tissue) may cause benign (that is, noncancerous) lumps in the breast. It is important for women to become familiar with their breasts and report changes (for example, lump, nipple discharge, and asymmetry) to their health care practitioner. In women, breast cancer is the second most common type of cancer and the second leading cause of cancer-related deaths. One in eight women in the United States will develop breast cancer during her lifetime. According to the National Cancer Institute (NCI) approximately 268,670 women in the United States will be diagnosed with invasive breast cancer in 2018, and 41,500 deaths are expected. The incidence of breast cancer rises after age 40. The highest incidence (approximately 80% of invasive cases) occurs in women over age 50. (NCI, 2018)

Astrocytomas and gliomas arise from the glial cells. Diffuse fibrillary astrocytomas are the most common type of brain tumor in adults. These tumors are classified histologically into three grades of malignancy: grade II astrocytoma, grade III anaplastic astrocytoma, and grade IV glioblastoma multiforme. Oligodendrogliomas are diffuse neoplasms that are clinically and biologically most closely related to the diffuse fibrillary astrocytomas. However, these tumors have generally better prognoses than diffuse astrocytomas with mean survival times of 10 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 individuals.

Definitions

Ablative: Very high dose of a treatment, calculated to kill a tumor.

Bone marrow: A spongy tissue located within flat bones, including the hip and breast bones and the skull; this tissue contains stem cells, the precursors of platelets, red blood cells, and white cells.

Chemotherapy: Medical treatment of a disease, particularly cancer, with drugs or other chemicals.

Chimerism: Cell populations derived from different individuals; may be mixed or complete.

Cytotoxic: Destructive to cells.

Graft versus host disease: A life-threatening complication of bone marrow transplants in which the donated marrow causes an immune reaction against the recipient’s body.

Hematopoietic stem cells: Primitive cells capable of replication and formation into mature blood cells in order to re-populate the bone marrow.

High-dose or myeloablative chemotherapy (HDC): The administration of cytotoxic agents using doses several times greater than the standard therapeutic dose.

HLA (human leukocyte antigen): A group of protein molecules located on bone marrow cells that can provoke an immune response.

Non-myeloablative chemotherapy: Less intense chemotherapy conditioning regimens, which rely more on immunosuppression than cytotoxic effects to permit engraftment of donor cells.

Tandem transplant: Planned administration of more than one cycle of high-dose or non-myeloablative chemotherapy, alone or with total body irradiation, each of which is followed by re-infusion of stem cells.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:

CPT

 

38204

Management of recipient hematopoietic progenitor cell donor search and cell acquisition

38205

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic

38206

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous

38207-38215

Transplant preparation of hematopoietic progenitor cells [includes codes 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215]

38230

Bone marrow harvesting for transplantation; allogeneic

38232

Bone marrow harvesting for transplantation; autologous

38240

Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor

38241

Hematopoietic progenitor cell (HPC); autologous transplantation

38243

Hematopoietic progenitor cell (HPC); HPC boost

 

 

HCPCS

 

S2142

Cord blood-derived stem cell transplantation, allogeneic

S2150

Bone marrow or blood-derived peripheral 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-10 Procedure

 

 

Autologous transplantation

30230G0-30263G0

Transfusion of autologous bone marrow [by site and approach; includes codes 30230G0, 30233G0, 30240G0, 30243G0, 30250G0, 30253G0, 30260G0, 30263G0]

30230Y0-30263Y0

Transfusion of autologous hematopoietic stem cells [by site and approach; includes codes 30230Y0, 30233Y0, 30240Y0, 30243Y0, 30250Y0, 30253Y0, 30260Y0, 30263Y0]

 

Allogeneic transplantation

30230G2-30243G4

Transfusion of allogeneic bone marrow, related, unrelated or unspecified into peripheral or central vein [by approach; includes codes 30230G2, 30230G3, 30230G4, 30233G2, 30233G3, 30233G4, 30240G2, 30240G3, 30240G4, 30243G2, 30243G3, 30243G4]

30250G1-30263G1

Transfusion of nonautologous bone marrow into peripheral or central artery [by approach; includes codes 30250G1, 30253G1, 30260G1, 30263G1]

30230X2-30243X4

Transfusion of allogeneic cord blood stem cells, related, unrelated or unspecified into peripheral or central vein [by approach; includes codes 30230X2, 30230X3, 30230X4, 30233X2, 30233X3, 30233X4, 30240X2, 30240X3, 30240X4, 30243X2, 30243X3, 30243X4]

30250X1-30263X1

Transfusion of nonautologous cord blood stem cells into peripheral or central artery [by approach; includes codes 30250X1, 30253X1, 30260X1, 30263X1]

30230Y2-30243Y4

Transfusion of allogeneic hematopoietic stem cells, related, unrelated or unspecified into peripheral or central vein [by approach; includes codes 30230Y2, 30230Y3, 30230Y4, 30233Y2, 30233Y3, 30233Y4, 30240Y2, 30240Y3, 30240Y4, 30243Y2, 30243Y3, 30243Y4]

30250Y1-30263Y1

Transfusion of nonautologous hematopoietic stem cells into peripheral or central artery [by approach; includes codes 30250Y1, 30253Y1, 30260Y1, 30263Y1]

 

Pheresis

6A550ZV

Pheresis of hematopoietic stem cells, single

6A551ZV

Pheresis of hematopoietic stem cells, multiple

 

 

ICD-10 Diagnosis

 

C00.0-C80.2

Malignant neoplasms [code range; when not specified as pediatric solid tumors or germ cell tumors]

G35

Multiple sclerosis

M05.00-M05.9

Rheumatoid arthritis with rheumatoid factor

M06.00-M06.09

Rheumatoid arthritis without rheumatoid factor

M08.00-M08.09

Unspecified juvenile rheumatoid arthritis

M08.20-M08.29

Juvenile rheumatoid arthritis with systemic onset

M32.0-M32.9

Systemic lupus erythematosus (SLE)

M34.0-M34.9

Systemic sclerosis (scleroderma)

References

Peer Reviewed Publications:

  1. Atkins HL, Bowman M, Allan D, et al. Immunoablation and autologous haemopoietic stem-cell transplantation for aggressive multiple sclerosis: a multicenter single-group phase 2 trial. Lancet. 2016; 388:576-585.
  2. Atkins H, Freedman M. Immunoablative therapy as a treatment for aggressive multiple sclerosis. Neurologic Clinics. 2005; 23(1):273-300, ix.
  3. Bhatia S, Abonour R, Porcu P, et al. High-dose chemotherapy as initial salvage chemotherapy in patients with relapsed testicular cancer. J Clin Oncol. 2000; 18(19):3346-3351.
  4. Burt RK, Balabanov R, Han X. Association of nonmyeloblative hematopoietic stem cell transplantation with neurologic disability in patients with relapsing-remitting multiple sclerosis. JAMA. 2015; 313(3):275-284.
  5. Burt RK, Loh Y, Cohen B, et al. Autologous non-myeloablative hematopoietic stem cell transplantation in relapsing-remitting multiple sclerosis: a phase I/II study. Lancet Neurol. 2009; 8(3):244-253.
  6. Burt RK, Marmont A, Oyama Y, et al. Randomized controlled trials of autologous hematopoietic stem cell transplantation for auto immune diseases. Arthritis Rheum. 2006; 54(12):3750-3760.
  7. Burt RK, Shah SJ, Dill K, et al. Autologous non-myeloablative haemopoietic stem-cell transplantation compared with pulse cyclophosphamide once per month for systemic sclerosis (ASSIST): an open-label, randomised phase 2 trial. Lancet. 2011; 378(9790):498-506.
  8. Burt RK, Traynor AE. Hematopoietic stem cell transplantation: a new therapy for autoimmune disease. Oncologist. 1999; 4(1):77-83.
  9. Carreras E, Saiz A, Marin P, et al. CD34+ selected autologous peripheral blood stem cell transplantation for multiple sclerosis: report of toxicity and treatment results at one year of followup in 15 patients. Haematologica. 2003; 88(3):306-314.
  10. Childs R, Barrett J. Nonmyeloablative stem cell transplantation for solid tumors: expanding the application of allogeneic immunotherapy. Semin Hematol. 2002; 39(1):63-71.
  11. Coleman RE. High dose chemotherapy: Rationale and results in breast carcinoma. Cancer. 2000; 88(12 Suppl):3059-3064.
  12. Elfenbein GJ. Stem-cell transplantation for high-risk breast cancer. N Engl J Med. 2003; 349(1):80-82.
  13. Euler HH, Marmont AM, Bacigalupo A, et al. Early recurrence or persistence of autoimmune disease after unmanipulated autologous stem cell transplantation. Blood. 1996; 88(9):3621-3625.
  14. Good RA, Verjee T. Historical and current perspectives on bone marrow transplantation for prevention and treatment of immunodeficiencies and autoimmunities. Biol Blood Marrow Transplant. 2001; 7(3):123-135.
  15. Hartmann O, Le Corroller AG, Blaise D, et al. Peripheral blood stem cell and bone marrow transplantation for solid tumors and lymphomas. Ann Intern Med. 1997; 126(8):600-607.
  16. Mahdi-Rogers M, Kazmi M, Ferner R, et al. Autologous peripheral blood stem cell transplantation for chronic acquired demyelinating neuropathy. J Peripher Nerv Syst. 2009; 14(2):118-124.
  17. Mancardi GL, Sormani MP, Gualandi F, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis: a phase II trial. Neurology. 2015; 84(10):981-988.
  18. McSweeney PA, Nash RA, Sullivan KM, et al. High-dose immunosuppressive therapy for severe systemic sclerosis: initial outcomes. Blood. 2002; 1000(5):1602-1610.
  19. Muraro PA, Pasquini M, Atkins HL, et al. Long-term outcomes after autologous hematopoietic stem cell transplantation for multiple sclerosis. JAMA Neurol. 2017; 74(4):459-469.
  20. Nash RA1, Hutton GJ2, Racke MK2, et al. High-dose immunosuppressive therapy and autologous HCT for relapsing-remitting MS. Neurology. 2017; 88(9):842-852.
  21. Nash RA, McSweeney PA, Crofford LJ, et al. High-dose immunosuppressive therapy and autologous hematopoietic cell transplantation for severe systemic sclerosis: long-term follow-up of the US multicenter pilot study. Blood 2007; 110(4):1388-1396.
  22. Nelson RP Jr, Logan TF, Abonour R. Nonablative hematopoietic cell transplantation for the treatment of metastatic renal cell carcinoma. Bone Marrow Transplant. 2002; 30(12):805-812.
  23. Openshaw H, Lund BT, Kashyap A, et al. Peripheral blood stem cell transplantation in multiple sclerosis with busulfan and cyclophosphamide conditioning: report of toxicity and immunological monitoring. Biol Blood Marrow Transplant. 2000; 6:568-575.
  24. Reston JT, Uhl S, Treadwell JR et al. Autologous hematopoietic cell transplantation for multiple sclerosis: a systematic review. Mult Scler 2011; 17(2):204-213.
  25. Rodenhuis S, Bontenbal M, Beex LV, et al. High-dose chemotherapy stem-cell rescue for high-risk breast cancer. N Engl J Med. 2003; 349(1):7-16.
  26. Sarosy GA. Autologous stem-cell transplantation in ovarian cancer: is more better? Ann Intern Med. 2000; 133(7):555-556.
  27. Shevchenko YL, Novik AA, Kuznetsov AN, et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Exp Hematol. 2008; 36(8):922-928.
  28. Stiff PJ, Veum-Stone J, Lazarus HM, et al. High-dose chemotherapy and autologous stem-cell transplantation for ovarian cancer: an autologous blood and marrow transplant registry report. Ann Intern Med. 2000; 133(7):813-820.
  29. Storb RF, Lucarelli G, McSweeney PA, Childs RW. Hematopoietic cell transplantation for benign hematologic disorders and solid tumors. Hematology Am Soc Hematol Educ Program. Hematology. 2003: 372-397.
  30. Su L, Xu J, Ji BX, et al. Autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Int J Hematol. 2006; 84(3):276-281.
  31. Sullivan KM, Goldmuntz EA, Keyes-Elstein L, et al. Myeloablative autologous stem-cell transplantation for severe scleroderma. N Engl J Med. 2018; 378(1):35-47.
  32. Tallman MS, Gray R, Robert NJ, et al. Conventional adjuvant chemotherapy with or without high-dose chemotherapy and autologous stem-cell transplantation in high-risk breast cancer. N Engl J Med. 2003; 349(1):17-26.
  33. Van Laar JM, Farge D, Sont JK, et al. Autologous hematopoietic stem cell transplantation vs intervenous pulse cyclophosphamide in diffuse cutaneous systemic sclerosis: a randomized clinical trial. JAMA. 2014; 331(24):2490-2498.
  34. Van Laar JM, Tyndall A. Intense immunosuppression and stem-cell transplantation for patients with severe rheumatic autoimmune disease: a review. Cancer Control. 2003; 10(1):57-65.
  35. Vonk MC, Marjanovic Z, van den Hoogen FH, et al. Long-term follow-up results after autologous haematopoietic stem cell transplantation for severe systemic sclerosis. Ann Rheum Dis. 2008; 67(1):98-104.
  36. Wedderburn LR, Abinun M, Palmer P, Foster HE. Autologous hematopoietic stem cell transplantation in juvenile idiopathic arthritis. Arch Dis Child. 2003; 88(3):201-205.
  37. Weiss RB. The randomized trials of dose-intensive therapy for breast cancer: what do they mean for patient care and where do we go from here? The Oncologist. 1999; 4(6):450-458.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determination for Stem Cell Transplantation. NCD #110.23. Effective January 27, 2016. Available at: http://www.cms.gov/mcd/index_list.asp?list_type=ncd. Accessed on March 22, 2018.
  2. Farquhar C, Marjoribanks J, Basser R, et al. High dose chemotherapy and autologous bone marrow or stem cell transplantation versus conventional chemotherapy for women with early poor prognosis breast cancer. Cochrane Database Syst Rev. 2005;(3):CD003139.
  3. Griffith LM, Pavletic SZ, Tyndall A, et al. Feasibility of allogeneic hematopoietic stem cell transplantation for autoimmune disease: position statement from a National Institute of Allergy and Infectious Diseases and National Cancer Institute-sponsored international workshop, Bethesda, MD, March 12 and 13, 2005. Biol Blood Marrow Transplant. 2005; 11(11):862-870.
  4. National Institute of Allergy and Infectious Disease (NIAID). High-dose immunosuppression and autologous transplantation for multiple sclerosis (HALT-MS) study. NLM Identifier: NCT00288626. Last updated September 19, 2017. Available at: https://clinicaltrials.gov/ct2/show/NCT00288626?term=NCT00288626&rank=1. Accessed on April 2, 2018.
  5. National Institute of Allergy and Infectious Diseases (NIAID). Scleroderma: cyclophosphamide or transplantation (SCOT). NLM Identifier: NCT00114530. Last updated on January 29, 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT00114530?term=NCT00114530&rank=1. Accessed on: March 22, 2018.
  6. Northwestern University. Stem Cell Therapy for Patients With Multiple Sclerosis Failing Alternate Approved Therapy- A Randomized Study. NLM Identifier: NCT00273364. Last updated on July 29, 2017. Available at: http://www.clinicaltrials.gov/ct2/show/NCT00273364?term=Multiple+sclerosis+and+stem+cell&rank=13. Accessed on March 22, 2018.
Websites for Additional Information
  1. American Cancer Society. Available at: http://www.cancer.org/docroot/home/index.asp. Accessed on March 22, 2018.
  2. National Cancer Institute. Bone-forming stem cell transplantation: questions and answers. Reviewed August 12, 2013. Available at: http://www.cancer.gov/cancertopics/factsheet/Therapy/bone-marrow-transplant. Accessed on March 22, 2018.
  3. National Cancer Institute. Breast cancer (PDQ®) - Health Professional Version. Last modified February 4, 2018. Available at: https://www.cancer.gov/types/breast/hp/breast-treatment-pdq. Accessed on March 27, 2018.
  4. National Library of Medicine. Medline Plus. Bone Marrow Transplantation. Available at: http://www.nlm.nih.gov/medlineplus/bonemarrowtransplantation.html. Accessed on March 22, 2018.
Index

Autoimmune Disease
Mini Transplant
Non-Myeloablative Stem Cell Transplant
Peripheral Blood Stem Cell
Solid Tumor
Stem Cell Support (SCS)
Stem Cell Transplant (SCT)

Document History

Status

Date

Action

Reviewed

05/03/2018

Medical Policy & Technology Assessment Committee (MPTAC) review.

Reviewed

05/02/2018

Hematology/Oncology Subcommittee review. The document header wording updated from “Current Effective Date” to “Publish Date”. Updated Rationale, References and Websites sections.

Reviewed

05/04/2017

MPTAC review.

Reviewed

05/03/2017

Hematology/Oncology Subcommittee review. Updated Rationale, References and Websites sections.

 

10/01/2016

Updated Coding section with 10/01/2016 ICD-10-PCS procedure code changes.

Revised

05/05/2016

MPTAC review.

Revised

05/04/2016

Hematology/Oncology Subcommittee review. Reformatted criteria removing abbreviations from MN position. Updated Rationale, Background, References and Websites sections. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review.

Reviewed

05/06/2015

Hematology/Oncology Subcommittee review. Updated Rationale, Definitions, References and Websites.

Reviewed

05/15/2014

MPTAC review.

Reviewed

05/14/2014

Hematology/Oncology Subcommittee review. Updated Rationale, References and Websites.

Reviewed

05/09/2013

MPTAC review.

Reviewed

05/08/2013

Hematology/Oncology Subcommittee review. Updated Rationale, References and Websites.

 

01/01/2013

Updated Coding section with 01/01/2013 CPT changes.

Revised

05/10/2012

MPTAC review.

Revised

05/09/2012

Hematology/Oncology Subcommittee review. Revised investigational and not medically positions to include autologous or allogeneic (ablative and non-myeloablative “[mini-transplant]”) hematopoietic stem cell transplantation “single or tandem”. Removed redundant investigational and not medically necessary statements for all conditions. Clarified investigational and not medically necessary statements for “adult miscellaneous” solid tumors Reformatted policy. Rationale, Background, References and Websites updated.

 

01/01/2012

Updated Coding section with 01/01/2012 CPT changes.

Reviewed

05/19/2011

MPTAC review.

Reviewed

05/18/2011

Hematology/Oncology Subcommittee review. Websites, Coding and References updated.

Reviewed

05/13/2010

MPTAC review.

Reviewed

05/12/2010

Hematology/Oncology Subcommittee review. Websites and references updated.

Revised

11/19/2009

MPTAC review.

Revised

11/18/2009

Hematology/Oncology Subcommittee review. Changed title to Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors. Clarified position statements. Rationale, background, websites and references updated.

Reviewed

05/21/2009

MPTAC review.

Reviewed

05/20/2009

Hematology/Oncology Subcommittee review. Rationale, websites and references updated. No change to position

Reviewed

05/15/2008

MPTAC review.

Reviewed

05/14/2008

Hematology/Oncology Subcommittee review. Rationale, websites and references updated. No change to position.

 

01/01/2008

Updated Coding section with 01/01/2008 HCPCS changes; removed HCPCS G0267 deleted 12/31/2007. The phrase “investigational/not medically necessary” was clarified to read “investigational and not medically necessary.” This change was approved at the November 29, 2007 MPTAC meeting.

Reviewed

05/17/2007

MPTAC review.

Reviewed

05/16/2007

Hematology/Oncology Subcommittee review. No change to position. References and coding updated.

Revised

12/07/2006

MPTAC review. References updated. Coding updated.

Revised

12/06/2006

Hematology/Oncology Subcommittee review

Reviewed

12/01/2005

MPTAC review.

Reviewed

11/30/2005

Hematology/Oncology Subcommittee review. Minor formatting changes.

 

11/22/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

04/28/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

10/28/2004

TRANS.00002

Stem Cell Transplant following Chemotherapy for Malignant Diseases

 

10/28/2004

TRANS.00003

Stem Cell Transplant following Chemotherapy for Non-Malignant Diseases

WellPoint Health Networks, Inc.

12/02/2004

7.11.02

Autologous Bone Marrow Transplantation or Peripheral Blood Stem Cell Support (PBSCS) for Malignancies

 

12/02/2004

7.11.03

Allogeneic Bone Marrow or Stem Cell Transplantation

 

12/02/2004

7.11.05

Mini-Transplants