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MP 8.01.35 |
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ-Cell Tumors |
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| Medical Policy | ||
| Section Therapy |
Original Policy Date 4/30/00 |
Last Review Status/Date Reviewed with literature search/12:2008 |
| Issue 12:2008 |
Return to Medical Policy Index |
Disclaimer
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Description
Hematopoietic Stem-Cell Transplantation
Hematopoietic stem-cell transplantation (SCT) refers to a procedure in which hematopoietic stem cells are infused to restore bone marrow function in cancer patients who receive bone marrow toxic doses of cytotoxic drugs with or without whole body radiation therapy. Bone marrow stem cells may be obtained from the transplant recipient (autologous SCT) or from a donor (allogeneic SCT). 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 is discussed in greater detail in policy No. 7.01.50.
Immunologic compatibility between infused stem cells and the recipient is not an issue in autologous SCT. However, immunologic compatibility between donor and patient is a critical factor for achieving a good outcome of allogeneic SCT. Compatibility is established by typing of human leukocyte antigens (HLA) using cellular, serologic, or molecular techniques. HLA refers to the tissue type expressed at the HLA A, B, and DR loci on each arm of chromosome 6. Depending on the disease being treated, an acceptable donor will match the patient at all or most of the HLA loci.
Tandem Transplant
Two or more planned courses of high-dose chemotherapy (HDC) and stem-cell support are referred to as “tandem transplantation.” Tandem transplants are typically administered at intervals of 2–6 months, contingent on recovery from treatment-related toxicity.
Conventional Preparative Conditioning for Hematopoietic SCT
The conventional practice of allogeneic SCT involves administration of myelotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to cause bone marrow failure. The beneficial treatment effect in this procedure results from chemotherapeutic eradication of malignant cells with an associated immune-mediated graft-versus-malignancy effect. While such treatment may eliminate the malignant cells, patients are as likely to die from opportunistic infections, graft-versus-host disease, and organ failure as from the underlying malignancy.
Autologous SCT necessitates myeloablative chemotherapy to eradicate cancerous cells, with subsequent engraftment and repopulation of the bone marrow space with hematopoietic progenitor cells. Patients who undergo autologous SCT are susceptible to toxicities related to chemotherapy and opportunistic infections prior to engraftment, but not graft-versus-host disease.
Reduced-Intensity Conditioning for Allogeneic SCT
Reduced-intensity conditioning (RIC) refers to chemotherapy regimens that seek to reduce adverse effects secondary to bone marrow toxicity while retaining the beneficial graft-versus-malignancy effect of allogeneic transplantation. These regimens do not eradicate the patient’s hematopoietic ability, thereby allowing for relatively prompt hematopoietic recovery (e.g., 28 days or less) even without a transplant. Patients who undergo RIC with allogeneic SCT initially demonstrate donor cell engraftment and bone marrow mixed chimerism. Most will subsequently convert to full-donor chimerism, which may be supplemented with donor lymphocyte infusions to eradicate residual malignant cells. A number of different cytotoxic regimens, with or without radiotherapy, may be used for RIC allotransplantation. They represent a continuum in their effects, from nearly totally myeloablative, to minimally myeloablative with lymphoablation.
SCT in Solid Tumors
SCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults continues to be largely experimental. Initial enthusiasm for the use of autologous transplant with the use of high-dose chemotherapy and stem cells for solid tumors has waned with the realization that dose intensification often fails to improve survival, even in tumors with a linear-dose response to chemotherapy. (1) With the advent of nonmyeloablative allogeneic transplant, interest has shifted to exploring the generation of alloreactivity to metastatic solid tumors via a graft-versus-tumor effect of donor-derived T cells. (2)
Germ-Cell Tumors
Germ-cell tumors (GCT) are composed primarily of testicular neoplasms (seminomas or nonseminomatous GCT) but also include ovarian and extragonadal GCTs (e.g., retroperitoneal or mediastinal tumors). GCTs are classified according to their histology, stage, prognosis, and response to chemotherapy.
Histologies include seminoma, embryonal carcinoma, teratoma, choriocarcinoma, yolk sac tumor, and mixed germ-cell tumors. Seminomas are the most common; all other types are collectively referred to as nonseminomatous GCT.
Stage is dependent on location and extent of the tumor, using the American Joint Committee on Cancer’s TNM system. TNM stages, modified by serum concentrations of markers for tumor burden (S0-3) when available, are grouped by similar prognoses. Markers used for GCTs include human beta-chorionic gonadotropin (HCG), lactate dehydrogenase (LDH), and alpha fetoprotein (AFP). However, most patients with pure seminoma have normal AFP concentrations. For testicular tumors, Stages IA-B have tumors limited to the testis (no involved nodes or distant metastases) and no marker elevations (S0); Stages IIA-C have increasing size and number of tumor-involved lymph nodes, and at least one marker moderately elevated above the normal range (S1); and Stages IIIA-C have distant metastases and/or marker elevations greater than specified thresholds (S2-3).
GCTs also are divided into good-, intermediate-, or poor-risk categories based on histology, site, and extent of primary tumor, and on serum marker levels. Good-risk pure seminomas can be at any primary site, but are without nonpulmonary visceral metastases or marker elevations. Intermediate-risk pure seminomas have nonpulmonary visceral metastases with or without elevated HCG and/or LDH. There are no poor-risk pure seminomas, but mixed histology tumors and seminomas with elevated AFP are managed as nonseminomatous GCTs. Good- and intermediate-risk non-seminomatous GCTs have testicular or retroperitoneal tumors without nonpulmonary visceral metastases, and either S1 (good risk) or S2 (intermediate) levels of marker elevations. Poor-risk tumors have mediastinal primary tumors, or nonpulmonary visceral metastases, or the highest level (S3) of marker elevations.
Therapy for GCT is generally dictated by stage, risk subgroup and tumor histology. Testicular cancer is divided into seminomatous and nonseminomatous types for treatment planning because seminomas are more sensitive to radiation therapy. Stage I testicular seminomas may be treated by orchiectomy with or without radiation or single-dose carboplatin adjuvant therapy. Nonseminomatous stage I testicular tumors may be treated with orchiectomy with or without retroperitoneal lymph node dissection. Higher stage disease typically involves treatment that incorporates chemotherapy. First-line chemotherapy for good- and intermediate-risk patients with higher-stage disease is usually 3 or 4 cycles of a regimen combining cisplatin and etoposide, with or without bleomycin depending on histology and risk group. Chemotherapy is often followed by surgery to remove residual masses. Second-line therapy often consists of combined therapy with ifosfamide/mesna and cisplatin, plus vinblastine, paclitaxel, or etoposide (if not used for first-line treatment). Patients whose tumors are resistant to cisplatin may receive carboplatin-containing regimens. The probability of long-term continuous complete remission diminishes with each successive relapse. Experience with repeated relapses after chemotherapy and disappointing results in poor-risk patients have prompted investigations of HDC with hematopoietic stem-cell support.
Policy
Autologous stem-cell transplant may be considered medically necessary to treat patients with germ-cell tumors in second complete remission or in second relapse. Autologous stem-cell transplant may also be considered medically necessary as salvage therapy for poor-risk germ-cell tumors that do not achieve complete remission after primary chemotherapy with or without surgery (i.e., those achieving a partial response or less, and those with refractory disease).
Autologous stem-cell transplant is considered investigational as a component of first-line treatment for poor-risk germ-cell tumors, or as initial treatment of a first relapse (i.e., in lieu of a course of conventional chemotherapy).
Tandem autologous stem-cell transplant is considered investigational to treat germ-cell tumors of any stage.
Allogeneic stem-cell transplant is considered investigational to treat germ-cell tumors, including, but not limited to its use as therapy after a prior failed course of high-dose chemotherapy with autologous stem-cell support.
Policy Guidelines
The term “partial response” is defined as at least a 50% reduction in tumor burden.
The term “refractory” is defined as a less than 50% reduction in tumor burden. Therefore, tumors that exhibited a 30% reduction in tumor burden, for example, would be considered refractory. Tumor response can be measured using serial computed tomography (CT) scans, or levels of circulating tumor markers (HCG, LDH, or AFP).
In 2003, CPT centralized codes describing allogeneic and autologous hematopoietic stem-cell support services to the hematology section (CPT 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38240, 38241 & 38242). Not all codes are applicable for each HDC/stem-cell support procedure. For example, Plans should determine if cryopreservation is performed. A range of codes describes services associated with cryopreservation, storage, and thawing of cells (38208, 38209, 38210, 38211, 38212, 38213, 38214 & 38215).
CPT 38208 and 38209 describe thawing and washing of cryopreserved cells
CPT 38210, 38211, 38212, 38213 & 38214 describe certain cell types being depleted
CPT 38215 describes plasma cell concentration
Benefit Application
BlueCard/National Account Issues
The following considerations may supersede this policy:
- State mandates requiring coverage for autologous bone marrow transplantation offered as part of NIH-approved clinical trials of autologous bone marrow transplantation.
- Some plans may participate in voluntary programs offering coverage for patients participating in NIH-approved clinical trials of cancer chemotherapies, including autologous bone marrow transplantation.
- Some contracts or certificates of coverage (e.g., FEP) may include specific conditions in which autologous bone marrow transplantation would be considered eligible for coverage.
Rationale
This policy was initially based on a 1991 TEC Assessment (1) that was updated with literature published between 1991 and April 2000. The 1991 TEC Assessment offered the following conclusions:
- Data were insufficient to permit conclusions about the outcomes of HDC and autologous stem-cell support as a component of initial therapy in patients with poor-risk tumors, or after a first relapse following initial standard-dose chemotherapy.
- Data demonstrated that, compared with conventional chemotherapy, outcomes after HDC and autologous stem-cell support were improved in patients with germ-cell tumors in second or subsequent relapse.
The literature published from 1991 through April 2000 did not change these conclusions. The most thorough review, published in 1999, was that of Sobecks and Vogelzang. (2) This review pooled results of 6 studies focusing on high-dose therapy in first-line treatment of germ-cell tumors. Only 2 studies reported survival, and it was unclear whether long-term survival was better than after conventional-dose therapy for comparable patients. Sobecks and Vogelzang also pooled results of 5 small studies focusing on high-dose therapy to treat germ-cell tumors at first relapse. The rate of continuous complete response was 56%, with an estimated median duration of 29 months. Treatment-related mortality was 5%. In contrast, conventional-dose chemotherapy achieves 5-year disease-free survival of 30% and treatment-related mortality of 2% or less. Since HDC carries a higher risk of initial treatment-related mortality, it is important to compare the long-term survival after conventional therapy with long-term survival after HDC.
The data published from 1991 through April 2000 also confirmed the beneficial effect of HDC and autologous stem-cell support in patients with germ-cell tumors in second or subsequent relapse, as concluded by the 1991 TEC Assessment.
There were scattered reports on use of tandem courses of HDC. However, there were no controlled studies demonstrating that outcomes of tandem transplants were superior to those of a single course of HDC. (3)
A 1999 TEC Assessment (4) evaluated outcomes of HDC and allogeneic stem-cell support as salvage therapy for germ-cell tumors after a failed prior course of autologous stem-cell transplant. A thorough review of the published literature identified no references reporting outcomes of this approach to HDC.
This policy was updated again in December 2002 based on a literature search performed in November 2002. The only randomized controlled trial among the new studies tested the impact of amifostine on peripheral blood mobilization prior to HDC. (5) Other recent studies reported outcomes of HDC as upfront (i.e., initial) treatment for poor prognosis/high-risk germ-cell tumors, primary salvage therapy of relapsed germ-cell tumor, salvage therapy for second or later relapse, or to treat refractory germ-cell tumors. These were uncontrolled clinical series enrolling small numbers of patients, or retrospective reviews of larger cohorts treated at one or several institutions. None of the studies compared outcomes of HDC to outcomes of conventional-dose chemotherapy in a randomized or nonrandomized trial, and many included patients in multiple prognostic or risk categories. As such, these studies do not permit conclusions regarding health outcomes of HDC and do not support a change in current policy; recent reviews on the status of HDC reach similar conclusions. (6-9)
2005-6 Update
Updated MEDLINE searches of the peer-reviewed literature identified no clinical trial publications that would alter the above conclusions. In 2005, Pico and colleagues reported on a randomized trial comparing 4 cycles of conventional-dose chemotherapy to three cycles of the same regimen followed by carboplatin-based HDC plus autologous stem cell support in 280 patients who had relapsed after a complete or partial remission following first-line therapy with a cisplatin-based regimen. (10) The authors reported no significant differences between treatment arms in 3-year event-free survival and overall survival. However, the study began before international consensus (11) established the current risk group definitions; thus, Pico et al. likely included some patients now considered to have good prognosis at relapse. Furthermore, while 77% and 86% of patients in the control and experimental arms, respectively, had at least one elevated serum tumor marker, they did not report how highly elevated these were and did not compare arms with respect to the marker thresholds that presently determine risk level (S1-3). Finally, HDC in the experimental arm followed 3 cycles of conventional-dose chemotherapy, which differs from most current practice in the U.S., where a single cycle is used prior to HDC. As a consequence, 38 of 135 (28%) randomized to the HDC arm did not receive HDC because of progression, toxicity, or withdrawal of consent. For all these reasons, the Pico study does not alter conclusions or current policy on HDC as a component of therapy for poor-risk relapse.
An Intergroup Phase III trial on HDC as part of first-line therapy for poor prognosis GCT was presented at a recent national meeting, but has not yet been published. (12) The trial compared 4 cycles of conventional dose chemotherapy (n=111) versus two cycles of the same regimen followed by two cycles of HDC and autologous stem cells (n=108). Investigators reported HDC did not significantly increase the proportion with a durable complete remission at 1 year, event-free, or overall survival. These outcomes support current policy on HDC for first-line therapy of poor-risk GCT.
A Phase II study on 3 cycles of tandem HDC regimens in 45 refractory, poor-prognosis patients by Lotz et al. was identified. (13) The authors reported some patients (with a Beyer score >2) did not benefit from tandem HDC and suggested that further study is needed. A randomized trial presented at the American Society of Clinical Oncology (ASCO) 2006 meeting but not yet published compared 1 cycle of HDC after 3 cycles of conventional-dose therapy versus 3 cycles of HDC after 1 cycle of conventional-dose therapy. (14) Conventional-dose therapy was etoposide (VP16), ifosfamide, and cisplatin (the VIP regimen), while HDC was carboplatin and etoposide. The trial was stopped early because of excess toxicity in the arm given 3 cycles of VIP before HDC. Investigators reported no significant differences between arms in overall or event-free survival. Neither of these reports changes conclusions or the policy statement on tandem transplants.
The 2006 National Comprehensive Cancer Network (NCCN) guidelines on testicular cancer (15) recommend high-dose chemotherapy when there is an incomplete response to first-line therapy or in second relapse when there is an incomplete response or subsequent relapse. The NCCN guidelines are consistent with current policy.
A search of the National Cancer Institute’s Physician Data Query database identified one open phase III randomized study of standard cisplatin, etoposide, and ifosfamide (VIP) followed by sequential high-dose VIP and stem-cell rescue versus bleomycin, etoposide, and cisplatin (BEP) in chemotherapy-naive men ages 16–50 with poor-prognosis germ-cell cancer (protocols EORTC-30974, NCT00003941). This trial is organized by the European Organization for Research and Treatment of Cancer and expects to accrue 222 patients within 2 years.
2007 Update
A literature review was done using MEDLINE through June 2007. Motzer and colleagues reported on a randomized trial of chemotherapy with or without high-dose chemotherapy in 219 previously untreated patients with poor-prognosis germ cell tumors. (16) In this trial, patients received either 4 cycles of standard bleomycin, etoposide, and cisplatin (BEP), or 2 cycles of BEP followed by 2 cycles of HDC with autologous stem cell rescue. The one-year durable complete response rate was 52% after BEP and HDC, and 48% after BEP alone (p=0.53). This study is consistent with the current policy statements.
Einhorn and colleagues reported on a series of 184 patients, treated between 1996 and 2004, with two consecutive cycles of high-dose chemotherapy for metastatic testicular cancer that had progressed (relapsed) after receiving cisplatin-containing combination chemotherapy. (17) Results from this experienced center showed that of the 184 patients, 116 had complete remission of disease without relapse during a median follow-up of 48 months. Of the 135 patients who received the treatment as second-line therapy, 94 (70%) were disease-free during follow-up; 22 (45%) of 49 patients who received treatment as third-line or later therapy were disease-free. Of 40 patients with cancer that was refractory to standard-dose platinum, 18 (45%) were disease-free. These results from this highly-specialized center are quite encouraging. However, until similar results are reported from other centers, the policy statement concerning tandem treatments is unchanged.
The 2007 NCCN guidelines for testicular cancer are also consistent with the current policy statements. (18)
2008 Update
Updated MEDLINE searches of the peer-reviewed literature identified no clinical trial publications that would alter the policy statements.
Lazarus et al. reported the results of autotransplant in relapsed testicular/germ-cell cancer from registry data from the Center for International Blood and Marrow Transplant Research. (19) Data included 300 patients from 76 transplant centers in 8 countries who received either a single transplant or tandem autotransplants between 1989 and 2001. Of the 300 patients, 102 received tandem, and 198 single planned autotransplants. Progression-free survival (PFS) and overall survival (OS) at 1, 3, and 5 years was similar for both groups. The probability of PFS at 5 years for the tandem transplant group was 34% (95% CI: 25-44%) versus 38% (95% CI: 31–45%) in the single transplant group; p =0.50. The probability of 5-year OS was 35% (95% CI: 25–46%) versus 42% (95% CI: 35–49%), respectively; p=0.29.
A search of the National Cancer Institute’s Physician Data Query database showed that the Phase III randomized study cited in the 2006 policy update is still ongoing, but not accruing patients (NCT00003941). No other Phase III trials investigating stem cell transplant for germ-cell tumors were identified.
The most recent NCCN guidelines for testicular cancer remain unchanged, and consistent with the current policy statements. (20)
References:
- TEC Assessments 1991; p 48.
- Sobecks RM, Vogelzang NJ. High dose chemotherapy with autologous stem-cell support for germ cell tumors: A critical review. Semin Oncol 1999; 26(1):106-18.
- Lotz JP, Andre T, Donsimoni R et al. High dose chemotherapy with ifosamide, carboplatin and etoposide combined with autologous bone marrow transplantation for the treatment of poor prognosis germ cell tumors and metastatic trophoblastic disease in adults. Cancer 1995; 75(3):874-85.
- TEC Assessments 1999; Tab 11.
- Rick O, Schwella N, Beyer J et al. PBPC mobilization with paclitaxel, ifosfamide, and G-CSF with or without amifostine: results of a prospective randomized trial. Transfusion 2001; 41(2):196-200.
- Beyer J, Rick O, Siegert W et al. Salvage chemotherapy in relapsed germ cell tumors. World J Urol 2001; 19(2):90-3.
- de Giorgi U, Rosti G, Papiani G et al. The status of high-dose chemotherapy with hematopoietic stem cell transplantation in patients with germ cell tumor. Haematologica 2002; 87(1):95-104.
- Kollmannsberger C, Mayer F, Kuczyk M et al. Treatment of patients with metastatic germ cell tumors relapsing after high-dose chemotherapy. World J Urol 2001; 19(2):120-5.
- Nichols CR. Chemotherapy of disseminated germ cell tumors. World J Urol 2001; 19(2):82-9.
- Pico JL, Rosti G, Kramar A et al. A randomised trial of high-dose chemotherapy in the salvage treatment of patients failing first-line platinum chemotherapy for advanced germ cell tumours. Ann Oncol 2005; 16(7):1152-9.
- International Germ Cell Cancer Collaborative Group. International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. J Clin Oncol 1997; 15(2):594-603.
- Bajorin DF, Nichols CR, Margolin KA et al. Phase III trial of conventional-dose chemotherapy alone or with high-dose chemotherapy for metastatic germ cell tumors (GCT) patients (PTS). A cooperative group trial by Memorial Sloan-Kettering Cancer Center, ECOG, SWOG, and CALGB. J Clin Oncol 2006; 24(18S): abstract 4510. Presented at 2006 ASCO Annual Meeting; video available online at:http://www.asco.org/portal/site/ASCO/menuitem. 64cfbd0f85cb37b2eda 2be0aee37a01d/?vgnextoid= 09f8201eb61a7010VgnVCM100000ed730ad1RCRD &vmview= vm_session_presentations_view&index= y&confID=40&trackID= 3&sessionID=351
- Lotz JP, Bui B, Gomez F et al. Sequential high-dose chemotherapy protocol for relapsed poor prognosis germ cell tumors combining two mobilization and cytoreductive treatments followed by three high-dose chemotherapy regimens supported by autologous stem cell transplantation. Results of the phase II multicentric TAXIF trial. Ann Oncol 2005; 16(3):411-8.
- Lorch A, Rick O, Hartmann JT et al. Single versus sequential high-dose chemotherapy in patients with relapsed or refractory germ-cell tumors (GCT). J Clin Oncol 2006; 24(18S): abstract 4511. Presented at 2006 ASCO Annual Meeting; video available on line at:http://www.asco.org/portal/site/ASCO/menuitem. 64cfbd0f85cb37b2eda2be0aee37a01d/?vgnextoid= 09f8201eb61a7010VgnVCM100000ed730ad1RCRD &vmview= vm_session_presentations_view&index= y&confID=40&trackID= 3&sessionID=351
- Testicular Cancer. Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network. V.1.2006. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf
- Motzer RJ, Nichols CJ, Margolin KA et al. Phase III randomized trial of conventional-dose chemotherapy with or without high-dose chemotherapy and autologous hematopoietic stem-cell rescue as first-line treatment for patients with poor-prognosis metastatic germ cell tumors. J Clin Oncol 2007; 25(3):247-56.
- Einhorn LH, Williams SD, Chamness A et al. High-dose chemotherapy and stem-cell rescue for metastatic germ-cell tumors. N Engl J Med 2007; 357(4):340-8.
- Testicular cancer. Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network. V.1.2007. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf Accessed September 10, 2007.
- Lazarus HM, Stiff PJ, Carreras J et al. Utility of single versus tandem autotransplants for advanced testes/germ cell cancer: A center for International Blood and Marrow Transplant Research (CIBMTR) analysis. Biol Blood Marrow Transplant 2007; 13(7):778-9.
- Testicular cancer. Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network. V.1.2009. http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf
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Codes |
Number |
Description |
| CPT | 38204 | Management of recipient hematopoietic 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 | |
| 38208 | Thawing of previously frozen harvest | |
| 38209 | Washing of harvest | |
| 38210 | Specific cell depletion with harvest, T-cell depletion | |
| 38211 | Tumor-cell depletion | |
| 38212 | Red blood cell removal | |
| 38213 | Platelet depletion | |
| 38214 | Plasma (volume) depletion | |
| 38215 | Cell concentration in plasma, mononuclear, or buffy coat layer | |
| 38220 | Bone marrow, aspiration only | |
| 38221 | Biopsy, needle or trocar | |
| 38240 | Bone marrow or blood-derived peripheral stem cell transplantation: allogeneic | |
| 38241 | Same as 38240 but autologous | |
| 86812, 86813, 86816, 86817, 86821, 86822 | Histocompatibility studies code range (e.g., for allogeneic transplant) |
|
| ICD-9 Procedure | 41.00 | Bone marrow transplant, not otherwise specified |
| 41.01 | Autologous bone marrow transplant | |
| 41.02 | Allogeneic bone marrow transplant with purging | |
| 41.03 | Allogeneic bone marrow transplant without purging | |
| 41.04 | Autologous hematopoietic stem-cell transplant | |
| 41.05 | Allogeneic hematopoietic stem-cell transplant | |
| 41.06 | Cord blood stem cell transplant | |
| 41.07 | Autologous hematopoietic stem cell transplant with purging | |
| 41.08 | Allogeneic hematopoietic stem cell transplant with purging | |
| 41.09 | Autologous bone marrow transplant with purging | |
| 41.91 | Aspiration of bone marrow from donor for transplant | |
| 99.79 | Other therapeutic apheresis (includes harvest of stem cells) | |
| ICD-9 Diagnosis | 158.0 | Malignant neoplasm of retroperitoneum |
| 164.2–164.9 | Malignant neoplasm of mediastinum code range | |
| 186.0–186.9 | Malignant neoplasm of testis code range | |
| HCPCS | G0265 | Cryopreservation, freezing, and storage of cells for therapeutic use, each cell line |
| G0266 | Thawing and expansion of frozen cells for therapeutic use, each cell line | |
| G0267 | Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastatic carcinoma) | |
| Q0083, Q0084, Q0085 | Chemotherapy administration code range | |
| J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9040, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9395, J9600, J9999 | Chemotherapy drugs code range | |
| S2140 | Cord blood harvesting for transplantation, allogeneic | |
| S2142 | Cord blood derived stem-cell transplantation, allogeneic | |
| S2150 | Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic, and emergency services). | |
| Type of Service | Therapy | |
| Place of Service | Inpatient/Outpatient | |
Index
Germ-cell tumors, high-dose chemotherapy
High-dose chemotherapy, germ-cell tumors
Seminoma, high-dose chemotherapy
Testicular cancer, high-dose chemotherapy
Policy History
| Date | Action | Reason |
| 04/30/00 | Add to Therapy section | New policy. Policy based on original master policy on high-dose chemotherapy for GCT. However, policy statement is unchanged |
| 12/18/02 | Replace policy | Update CPT codes only |
| 04/29/03 | Replace policy | Policy updated; policy statement unchanged |
| 03/15/05 | Replace policy | Literature review update for the period of October 2002 through December 2004; policy statement unchanged |
| 07/20/06 | Replace policy | Literature review update for the period of December 2004 through July 2006; description and medically necessary policy statement reworded regarding poor-risk germ-cell tumors; however, policy statements are otherwise unchanged. CPT codes updated in code table. |
| 09/18/07 | Replace policy | Policy updated with literature review through August 2007; no change in policy statements. Reference numbers 16 to 18 added. |
| 12/11/08 | Replace policy | Policy updated with literature review; terminology in policy statements changed; however, no change in intent of policy statements. Rationale extensively revised and “high-dose chemotherapy” removed from title. Reference numbers 19 and 20 added |
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