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MP 8.01.42 Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Medical Policy    
Section
Therapy 
Original Policy Date
10/9/03
Last Review Status/Date
Reviewed with literature search/2:2015
Issue
2:2015
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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

HSCT 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. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HSCT) or from a donor (allogeneic HSCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood 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 (GVHD). Cord blood is discussed in greater detail in Policy No. 7.01.50.

Immunologic compatibility between infused hematopoietic stem cells and the recipient is not an issue in autologous HSCT. However, immunologic compatibility between donor and patient is a critical factor for achieving a good outcome of allogeneic HSCT. Compatibility is established by typing 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.

Conventional Preparative Conditioning for HSCT

The conventional (“classical”) practice of allogeneic HSCT involves administration of cytotoxic agents (eg, cyclophosphamide, busulfan) with or without total-body irradiation at doses sufficient to destroy endogenous hematopoietic capability in the recipient. The beneficial treatment effect in this procedure is due to a combination of initial eradication of malignant cells and subsequent graft-versus-malignancy (GVM) effect that develops after engraftment of allogeneic stem cells within the patient’s bone marrow space. While the slower GVM effect is considered to be the potentially curative component, it may be overwhelmed by extant disease without the use of pretransplant conditioning. However, intense conditioning regimens are limited to patients who are sufficiently fit medically to tolerate substantial adverse effects that include pre-engraftment opportunistic infections secondary to loss of endogenous bone marrow function and organ damage and failure caused by the cytotoxic drugs. Furthermore, in any allogeneic HSCT, immune suppressant drugs are required to minimize graft rejection and GVHD, which also increases susceptibility of the patient to opportunistic infections.

The success of autologous HSCT is predicated on the ability of cytotoxic chemotherapy with or without radiation to eradicate cancerous cells from the blood and bone marrow. This permits subsequent engraftment and repopulation of bone marrow space with presumably normal hematopoietic stem cells obtained from the patient prior to undergoing bone marrow ablation. As a consequence, autologous HSCT is typically performed as consolidation therapy when the patient’s disease is in complete remission. Patients who undergo autologous HSCT are susceptible to chemotherapy-related toxicities and opportunistic infections prior to engraftment, but not GVHD.

Reduced-Intensity Conditioning for Allogeneic HSCT

Reduced-intensity conditioning (RIC) refers to the pretransplant use of lower doses or less intense regimens of cytotoxic drugs or radiation than are used in conventional full-dose myeloablative conditioning treatments. The goal of RIC is to reduce disease burden but also to minimize as much as possible associated treatment-related morbidity and nonrelapse mortality in the period during which the beneficial GVM effect of allogeneic transplantation develops. Although the definition of RIC remains arbitrary, with numerous versions employed, all seek to balance the competing effects of nonrelapse mortality and relapse due to residual disease. RIC regimens can be viewed as a continuum in effects, from nearly totally myeloablative to minimally myeloablative with lymphoablation, with intensity tailored to specific diseases and patient condition. Patients who undergo RIC with allogeneic HSCT 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. For the purposes of this policy, the term reduced-intensity conditioning will refer to all conditioning regimens intended to be nonmyeloablative, as opposed to fully myeloablative (conventional) regimens.

Primary Systemic Amyloidosis

The primary amyloidoses comprise a group of diseases with an underlying clonal plasma cell dyscrasia. They are characterized by the extracellular deposition of pathologic, insoluble protein fibrils with a beta-pleated sheet configuration that exhibit a pathognomonic red-green birefringence when stained with Congo red dye and examined under polarized light. These diseases are classified on the basis of the type of amyloidogenic protein involved, as well as by the distribution of amyloid deposits. In systemic amyloidosis, the unnatural protein is produced at a site that is remote from the site(s) of deposition, whereas in localized disease, the protein is produced at the site of deposition. Light-chain amyloidosis (AL), the most common type of systemic amyloidosis, has an incidence similar to that of Hodgkin’s lymphoma or chronic myelogenous leukemia, estimated at 5 to 12 people per million annually. The median age at diagnosis is approximately 60 years. The amyloidogenic protein in AL amyloidosis is an immunoglobulin light chain or light-chain fragment that is produced by a clonal population of plasma cells in the bone marrow. While the plasma cell burden in AL amyloidosis is typically low, ranging from 5% to 10%, this disease also may occur in association with multiple myeloma in 10% to 15% of patients. Deposition of AL amyloidogenic proteins causes organ dysfunction, most frequently in the kidneys, heart, and liver, although the central nervous system and brain may be affected.

Historically, this disease has had a poor prognosis, with a median survival from diagnosis of approximately 12 months, although outcomes have improved with the advent of combination chemotherapy with alkylating agents and autologous HSCT. Emerging approaches include the use of immunomodulating drugs such as thalidomide or lenalidomide, and the proteasome inhibitor bortezomib. Regardless of the approach chosen, treatment of AL amyloidosis is aimed at rapidly reducing the production of amyloidogenic monoclonal light chains by suppressing the underlying plasma cell dyscrasia, with supportive care to decrease symptoms and maintain organ function. The therapeutic index of any chemotherapy regimen is a key consideration in the context of underlying organ dysfunction.


Policy

Autologous hematopoietic stem-cell transplantation may be considered medically necessary to treat primary systemic amyloidosis.

Allogeneic hematopoietic stem-cell transplantation is considered investigational to treat primary systemic amyloidosis.


Policy Guidelines

 

In 2003, CPT centralized codes describing allogeneic and autologous HSCT services to the hematology section (38204-38242). Not all codes are applicable for each stem-cell transplant procedure. For example, Plans should determine if cryopreservation is performed. A range of codes describes services associated with cryopreservation, storage, and thawing of cells (38208-38215).

CPT 38208 and 38209 describe thawing and washing of cryopreserved cells

CPT 38210-38214 describe certain cell types being depleted

CPT 38215 describes plasma cell concentration


Benefit Application
BlueCard/National Account Issues

No applicable information


Rationale

This policy was originally created in 2003 and updated regularly with searches of the MEDLINE and EMBASE databases. The most recent literature review was performed for the period December 23, 2013, through December 2, 2014. Following is a summary of key literature to date.

Conventional therapy for primary systemic amyloidosis usually combines oral melphalan with prednisone (MP), which has been shown to yield higher response rates and longer survival than colchicine or prior therapies.(1-3) Median survival after oral melphalan with prednisone (±18 months) is longer than for untreated patients or those given older therapies (10-14 months), but more effective regimens have been sought. Combination therapy with vincristine, doxorubicin, and dexamethasone (VAD), a well-established regimen for myeloma, has been investigated.(1,2) However, because of its toxicity, VAD therapy usually is limited to patients without peripheral neuropathy or cardiomyopathy, both common  complications of amyloidosis. Because conventional regimens rarely cure systemic amyloidosis and because of the close biologic similarity to multiple myeloma, myeloablative chemotherapy with autologous HSCT was investigated for this disease.

Autologous Hematopoietic Stem Cell Transplantation

 

Initial results of autologous hematopoietic stem cell transplantation (HSCT) in uncontrolled patient series were published in 1998.(4,5) Clinical response rates (50%-60%) were nearly twice those reported for conventional therapy, and 2-year survival reportedly ranged from 56% to 68%.(2,6) However, procedurerelated mortality rates of 15% to 43% were substantially higher than those observed in myeloma patients, usually in cases that involved more than 2 organ systems or had symptomatic cardiac involvement.(5,7,8) A subsequent retrospective study analyzed outcomes of conventional therapy for primary amyloidosis in patients who would have been eligible for autologous HSCT.(6) Inclusion required age younger than 70 years, cardiac interventricular septal thickness less than 15, left ventricular ejection fraction (LVEF) more
than 55%, serum creatinine less than 2 mg/dL, and direct bilirubin less than 2.0 mg/dL. Patients eligible for transplantation but managed conventionally reportedly had median survival of 42 months after conventional treatment, compared with median survival of only 18 months for all patients with primary amyloidosis. Survival of conventionally managed patients (n=229) at 24 months was 61%, which was similar to 56% to 65% survival at 24 months after autologous HSCT.

In the same report, survival of 39 patients given autologous HSCT at their institution was compared with survival of a matched cohorts (n=78; 2 controls for each case) selected from their database of conventionally treated amyloidosis patients.(6) Factors used to match patients were limited to age (within 5 years), sex, and number of involved organs. They reported similar survival of cases and controls at 6 (85% vs 83%), 12 (77% vs 74%), and 24 months (68% and 60%, all respectively).

A follow-up report to the matched-pair analysis previously cited included a larger group of cases (n=63) treated with autologous HSCT and used parameters measuring severity of organ involvement to select matched controls (n=63).(9) Factors used for matching were age, sex, time to presentation, LVEF, serum creatinine, cardiac septal thickness, nerve involvement, 24-hour urinary protein excretion, and serum alkaline phosphatase. At a median follow-up of 3.5 years from diagnosis for each group, 16 transplanted patients and 44 controls had died. Kaplan-Meier analysis showed significantly greater overall survival (OS) for those given autotransplants (p=0.004). The survival rates for the high-dose and standard treatment groups at 1, 2, and 4 years were 89% and 71%; 81% and 55%; and 71% and 41%, respectively.

In addition to longer survival, evidence suggests improvement in symptoms for amyloidosis patients treated with autologous HSCT. In a large retrospective series of amyloidosis patients eligible for transplant (n=394), 63 patients declined treatment and 19 lost eligibility when they progressed before treatment started.(10) Estimated median survival for 312 patients who initiated stem cell mobilization was 4.6 years, but median follow-up was not reported. Of 181 evaluable patients (alive and followed-up for 1 year or more), 40% achieved complete hematologic response, defined as no evidence of plasma cell dyscrasia at 1 year after transplant. The authors reported functional improvement in at least 1 affected organ for 44% of evaluable patients: 66% of 73 patients with complete hematologic response, and 30% of 108 patients with an incomplete or no hematologic response. Among 277 patients who completed the transplant protocol, 36 (13%) died of treatment-related toxicity before day 100 posttransplant, 21 (8%) died between day 100 and 1 year, and 39 were alive but had not reached 1 year since transplant. This series included all patients transplanted between July 1994 and June 2002, of which one-half (n=196) had 3 or more organs involved and 43% had some cardiac involvement. Median survival for those with
cardiac involvement (n=137) was significantly shorter (1.6 vs 6.4 years, respectively; p<0.001) than for those without cardiac involvement (n=175).

A subsequent report based on the dataset from the large retrospective series outlined in the preceding paragraph provided an analysis of outcomes of risk-adjusted myeloablative melphalan and autologous HSCT in patients aged 65 years and older versus outcomes in those younger than 65 years, with up to 10 years of follow-up.(11) Patients younger than 65 years with LVEF of 45% or greater and adequate stem cell yield (n=280; median age, 55 years; range, 29-64 years) received melphalan 200 mg/m²; those aged 65 years and older, those with reduced LVEF (40%-45%), or those with lower stem cell yield (n=65; median age, 68 years; range, 65-79 years) received risk-adjusted melphalan 140 mg/m². No difference was observed in early treatment-related mortality (10.3% in patients ≥65 years vs 13.4% in those <65 years,
p=0.665). A trend toward a lower rate of hematologic complete response (CR, defined as the absence of clonal plasma cells in the bone marrow by immunohistochemical staining and of monoclonal gammopathy by immunofixation electrophoresis of serum and urine) was observed in older patients (27.6% for patients ≥65 years) versus 13.4% in those younger than 65 years (p=0.882). However, the median survival after autologous HSCT did not differ according to age (4.0 years for patients aged ≥65 years vs 4.85 years for those <65 years; log-rank, p=0.28).

A registry analysis of 107 amyloidosis patients who received transplants between 1995 and 2001 at 48 centers included 37 (35%) patients who received a transplant for initial therapy of amyloidosis, while 27 (25%) received a transplant after 2 or more prior therapies.(12) With a median follow-up of 30 months after transplant, OS at 1 and 3 years was 66% (95% confidence interval [CI], 56% to 75%) and 56% (95% CI, 45% to 66%), respectively. For those with no or 1 organ involved at transplant, survival at 1 year was 72% (95% CI, 61% to 82%), while for those with 2 or more organs involved, survival at 1 year was 54% (95% CI, 38% to 70%). Survival at 1 year also was greater for those without (69%; 95% CI, 58% to 79%) than with (56%; 95% CI, 37 to 74%) cardiac involvement. Treatment-related mortality at 30 days was 18% (95% CI, 11% to 26%), mostly among patients with cardiac and/or multiple organ involvement.

Long-term survival and outcomes were evaluated in a series of 80 patients with AL amyloidosis who were treated with myeloablative full-dose or risk-adjusted melphalan according to a risk-based protocol and underwent autologous HSCT.(13) All patients had a histologic diagnosis of amyloidosis with evidence of plasma cell dyscrasia and met eligibility criteria for autologous HSCT in clinical protocols. Patients (median age, 56 years; range, 29-71 years) received risk-adjusted melphalan 100 mg/m² (n=37) or fulldose melphalan 200 mg/m² (n=43) followed by autologous HSCT 24 to 72 hours after completion of the conditioning regimen. Treatment-related mortality was reported in 11 (14%) cases, 6 of whom had received risk-adjusted melphalan, while 5 received the full-dose regimen. Median survival for all 80 patients was 57 months; 18 (23%) were alive 10 or more years after undergoing autologous HSCT. Hematologic CR was assessed in 63 (79%) surviving patients at 1 year following treatment. Thirty-two of those patients (51%) achieved a hematologic CR; among those, median survival had not been reached at the time the report was prepared for publication. In contrast, the median survival for patients who failed to achieve a CR was 50 months, with a 6% estimated probability of survival at 10 years (p<0.001 vs patients with CR).

In a series of 282 consecutive patients with AL amyloidosis who underwent autologous HSCT, investigators sought to determine whether a hematologic CR, as determined by normalization of serum and urine monoclonal protein levels, provides an adequate surrogate marker for OS.(14) All patients had AL histologically verified with Congo red tissue stain and received risk-adjusted melphalan conditioning based on the presence of numbers of organs involved, creatinine level, age, and cardiac involvement. One third (n=93) of the patients received risk-adjusted melphalan (100 or 140 mg/m²) and 67% (n=189) received full-dose melphalan (200 mg/m²). The mortality at day 100 was 11%, with 28% of the cohort dead by the time this report was prepared. Ninety-three (33%) patients achieved a CR, 108 (38%) had a partial response (PR), and 36 (13%) had no response (NR) to autologous HSCT. Kaplan-Meier analysis showed that median survival was reached only in the NR group, compared with the CR and PR groups after more than 80 months of follow-up (log-rank, p<0.001 for NR vs CR and PR). An analysis (landmark analysis) focused on patients who survived for at least 6 months after autologous HSCT included 86 patients in the CR group, 91 who had PR, and 36 NR patients. This analysis showed that the survival curve differences remained significant between response groups as in the overall cohort, with a median survival of 40 months reached only in the NR group.

Patients with AL amyloidosis and cardiac involvement were treated in a series from Mayo Clinic.(15) A total of 187 patients of median age 57 years received high-dose melphalan followed by autologous HSCT. The median time from diagnosis to HSCT was about 4 months, and median estimated follow-up from diagnosis was 65 months (95% CI, 61 to 74 months). The median estimated OS for all 187 patients was 66 months (95% CI, 42 to 83 months). Overall, hematologic and cardiac responses were observed in 66% and 41% of patients, respectively. Overall, 30 (16%) patients died within 100 days of treatment; 29 of those deaths were considered to be the result of therapy.

A series of 421 consecutive patients treated with high-dose melphalan and autologous HSCT at a single referral center compared outcomes for patients with and without a CR.(16) Treatment-related mortality was about 11% overall (5.6% in the last 5 years). By intention-to-treat (ITT) analysis, the CR rate was 34% and the median event-free survival (EFS) and OS were 2.6 and 6.3 years, respectively. Eighty-one patients died within the first year after HSCT and were not evaluable for hematologic and organ response. Of 340 evaluable patients, 43% achieved CR and 78% of them experienced an organ response. For CR patients, median EFS and OS were 8.3 and 13.2 years, respectively. Among the 195 patients who did not obtain CR, 52% achieved an organ response, and their median EFS and OS were 2 and 5.9 years, respectively. Thus, treatment of selected AL amyloidosis patients with high-dose melphalan and autologous HSCT resulted in a high organ response rate and long OS, even for those patients who did not achieve CR. These results are compatible with others previously cited.

Several additional retrospective and prospective series have been reported on the use of autologous HSCT in patients with AL.(17-21) Results from these series are consistent with others that suggest autologous HSCT is feasible and beneficial in selected patients with AL amyloidosis.

One randomized multicenter trial involving 8 centers from the Myelome Autogreffe and Intergroupe Francophone du Myelome Intergroup has been reported in which conventional chemotherapy with melphalan plus dexamethasone was compared with myeloablative melphalan followed by autologous HSCT in patients with AL amyloidosis.(22) Patients between 18 and 70 years of age had a histologic diagnosis of AL amyloidosis and either a complete hematologic response characterization of amyloid deposits or evidence of a monoclonal immunoglobulin protein in the serum or urine or a monoclonal staining pattern of bone marrow plasma cells and had received no more than 2 courses of any chemotherapy regimen. They were randomly allocated, stratified according to age (<65 years or ≥65 years) and according to the affected organ system (cardiac, renal, neurologic, other). Of note, approximately two thirds of the patients had 2 or more organs affected. Patients in the melphalan plus dexamethasone group (n=50) received monthly courses of dose-adjusted (according to cytopenic status) oral melphalan, 10 mg/m² of body-surface area, on days 1 to 4 plus oral dexamethasone, 40 mg/d on days 1 to 4, for up to 18 courses if no severe adverse events occurred. In the autologous HSCT patients (n=50), hematopoietic stem cells were obtained from peripheral blood with granulocyte colony-stimulating factor mobilization. Melphalan was administered intravenously on day 0, and stem cells were infused on day 2, with the dose reduced from 200 mg/m² to 140 mg/m² for patients aged 65 years or older and for those with an LVEF less than 30%, a calculated creatinine clearance less than 30 mL/min, or severe liver disease. According to ITT analysis, the hematologic response rate did not differ between groups, with 12 CR (24%) and 14 PR (28%) in the melphalan-dexamethasone recipients versus 11 CR (22%) and 7 PR (14%) in the autologous HSCT group (p=0.11). At publication of the study, the median follow-up for the entire cohort was 24 months, and for survivors it was 36 months; 20 patients in the melphalandexamethasone group had died versus 31 in the autologous HSCT group. Among 65 patients who could be evaluated, the ITT median survival for patients assigned to melphalan plus dexamethasone was 56.9 months, versus 22.2 months in the autologous HSCT group (p=0.04). Survival rates and duration were significantly better in responders (CR plus PR) compared with NR (p<0.001). Analysis of patients who survived for at least 6 months and who received their assigned treatment, showed no significant difference in survival rates in patients assigned to melphalan plus dexamethasone compared with autologous HSCT, with neither group reaching median survival after 80 months (p=0.38).

Evidence from this randomized trial suggests autologous HSCT may be no more efficacious than conventional chemotherapy in prolonging survival among patients with AL amyloidosis. However, the results are limited by the size of the study, a lack of assessor blinding or allocation concealment, and a large attrition postrandomization. Thus, among 50 patients assigned to autologous HSCT, 13 (26%) did not receive the planned treatment (1 declined, 2 had insufficient stem cell harvest, 10 died before treatment), whereas 7 of 50 (14%) assigned to melphalan plus dexamethasone did not receive planned treatment (5 died before treatment, 1 did not tolerate treatment, 1 received incorrect treatment). Therefore, even though this was a randomized trial, the results are not sufficient to change the policy statement given the body of evidence available from other, albeit nonrandomized, studies.

A retrospective analysis from a single treatment center published in 2014 provides long-term evidence for improved survival among patients with AL amyloidosis who underwent autologous HSCT compared with conventional therapies (CTR).(23) Patients (median age at diagnosis, 59 years [range, 33-87 years]) underwent autologous HSCT (n=80) or CTR (n=65) following induction therapy that comprised pulse dexamethasone, bortezomib-dexamethasone, or other combinations of novel agents. Transplant recipients received a melphalan-based conditioning regimen that was adjusted according to the patient’s performance status and the treating physician’s clinical judgment. Patients were heterogeneous with respect to age, organ involvement, cardiac involvement, renal involvement, and percent of bone marrow blast cells, greater than 10%; all were significantly overrepresented in the CTR group compared with the HSCT group. Median follow-up was 3 years for the entire cohort, with some survivors followed for up to 14 years postdiagnosis. Median 5-year survival was 63% in the HSCT group compared with 38% in the CTR group (p<0.000); median survival at 10 years was 56% in the HSCT group and 10% in the CTR group (p<0.000). Among HSCT recipients, the transplant-related mortality rate was 7.5% at 100 days and 12.5% within 1 year of transplant. Adverse events other than transplant-related mortality were not reported. Although it is a retrospective analysis, with evident interstudy patient heterogeneity, this report suggests autologous HSCT may yield long-term survival in patients with this disease.

Allogeneic HSCT

Evidence on the use of allogeneic HSCT to treat AL amyloidosis is sparse, with no systematic evaluation in a clinical trial.(24) Concerns about the use of allogeneic HSCT include high treatment-related mortality (>40%), morbidity secondary to graft-versus-host disease, and questions about the efficacy of a proposed graft-versus-malignancy effect on low-grade plasma cell dyscrasias.

Ongoing and Unpublished Clinical Trials

A search of the National Cancer Institute Physician Data Query (PDQ) database on December 30, 2014, identified no active clinical studies specifically intended to investigate use of autologous or allogeneic HSCT to treat patients diagnosed with primary amyloidosis.

Clinical Input Received From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from no physician specialty societies and 5 academic medical centers, including 3 transplant centers, while this policy was under review in 2011. There was support for the policy statements regarding HSCT in the treatment of amyloidosis.

Summary of Evidence

Chemotherapy for the treatment of light-chain amyloidosis (AL) was introduced in 1972 in the form of melphalan and prednisone.(3) Median survival with this regimen was typically 12 to 18 months, with therapy remaining unchanged until the introduction of autologous hematopoietic stem cell transplantation (HSCT). The use of autologous HSCT for AL amyloidosis rapidly eradicates the amyloidogenic light chain produced by the clonal plasma cell populations, which is the proximal cause of pathology and subsequent death. This has extended survival rates to a reported 53% at 10 years in patients with a complete response to treatment.13 Transplant-related mortality rates have declined, from as high as 40% to 7% in current studies.25 Therefore, autologous HSCT is an important option for patients who are deemed eligible, and it is considered medically necessary. Evidence on the use of allogeneic HSCT is sparse and it remains investigational.

Practice Guidelines and Position Statements

The National Comprehensive Cancer Network published guidelines for Systemic Light Chain Amyloidosis (v1.2015).(26) A primary treatment option includes high-dose melphalan followed by stem cell transplant. In eligible patients, high-dose chemotherapy along with stem cell support has been associated with higher response rates and improved overall survival than standard chemotherapy. The guideline also cautions that the optimal therapy is not established and that such treatment would best be performed in a clinical trial.

U.S. Preventive Services Task Force Recommendations
Not applicable.

Medicare National Coverage
The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that when recognized clinical risk factors are employed to select patients for transplantation, high-dose melphalan together with autologous stem cell transplantation can provide a net health benefit for Medicare beneficiaries of any age group with primary AL amyloidosis. This technique is reasonable and necessary for patients of any age with primary AL amyloidosis who meet the following criteria:

  • amyloid deposition in 2 or fewer organs, and
  • cardiac left ventricular ejection fraction (EF) of greater than 45%.

To clarify existing coverage, autologous stem cell transplant must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy and/or radiotherapy used to treat various malignancies (http://www.cms.gov/medicare-coverage-database/details/ncadetails.aspx?NCAId=126&ExpandComments=n&NcaName=Autologous+Stem+Cell+Transplantation+(AuSCT)+for+Amyloidosis&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=amyloidosis&KeyWordLookUp=Title&KeyWordSearchType=And&from2=search.asp&bc=gAAAABAAAgAAAA%3d%3d&).

References:

  1. Gertz MA, Lacy MQ, Dispenzieri A. Amyloidosis: recognition, confirmation, prognosis, and therapy. Mayo Clin Proc. May 1999;74(5):490-494. PMID 10319082
  2. Comenzo RL, Gertz MA. Autologous stem cell transplantation for primary systemic amyloidosis. Blood. Jun 15 2002;99(12):4276-4282. PMID 12036853
  3. Jones NF, Hilton PJ, Tighe JR, et al. Treatment of "primary" renal amyloidosis with melphalan. Lancet. Sep 23 1972;2(7778):616-619. PMID 4116774
  4. Comenzo RL, Vosburgh E, Falk RH, et al. Dose-intensive melphalan with blood stem-cell support for the treatment of AL (amyloid light-chain) amyloidosis: survival and responses in 25 patients. Blood. May 15 1998;91(10):3662-3670. PMID 9573002
  5. Moreau P, Leblond V, Bourquelot P, et al. Prognostic factors for survival and response after high-dose therapy and autologous stem cell transplantation in systemic AL amyloidosis: a report on 21 patients. Br J Haematol. Jun 1998;101(4):766-769. PMID 9674753
  6. Dispenzieri A, Lacy MQ, Kyle RA, et al. Eligibility for hematopoietic stem-cell transplantation for primary systemic amyloidosis is a favorable prognostic factor for survival. J Clin Oncol. Jul 15 2001;19(14):3350-3356. PMID 11454882
  7. Gertz MA, Lacy MQ, Dispenzieri A. Myeloablative chemotherapy with stem cell rescue for the treatment of primary systemic amyloidosis: a status report. Bone Marrow Transplant. Mar 2000;25(5):465-470. PMID 10713619
  8. Saba N, Sutton D, Ross H, et al. High treatment-related mortality in cardiac amyloid patients undergoin autologous stem cell transplant. Bone Marrow Transplant. Oct 1999;24(8):853-855. PMID 10516696
  9. Dispenzieri A, Kyle RA, Lacy MQ, et al. Superior survival in primary systemic amyloidosis patients undergoing peripheral blood stem cell transplantation: a case-control study. Blood. May 15 2004;103(10):3960-3963. PMID 14739213
  10. Skinner M, Sanchorawala V, Seldin DC, et al. High-dose melphalan and autologous stem-cell transplantation in patients with AL amyloidosis: an 8-year study. Ann Intern Med. Jan 20 2004;140(2):85-93. PMID 14734330
  11. Seldin DC, Anderson JJ, Skinner M, et al. Successful treatment of AL amyloidosis with high-dose melphalan and autologous stem cell transplantation in patients over age 65. Blood. Dec 1 2006;108(12):3945-3947. PMID 16926284
  12. Vesole DH, Perez WS, Akasheh M, et al. High-dose therapy and autologous hematopoietic stem cell transplantation for patients with primary systemic amyloidosis: a Center for International Blood and Marrow Transplant Research Study. Mayo Clin Proc. Jul 2006;81(7):880-888. PMID 16835967
  13. Sanchorawala V, Skinner M, Quillen K, et al. Long-term outcome of patients with AL amyloidosis treated with high-dose melphalan and stem-cell transplantation. Blood. Nov 15 2007;110(10):3561-3563. PMID 17673601
  14. Gertz MA, Lacy MQ, Dispenzieri A, et al. Effect of hematologic response on outcome of patients undergoing transplantation for primary amyloidosis: importance of achieving a complete response. Haematologica. Oct 2007;92(10):1415-1418. PMID 17768110
  15. Madan S, Kumar SK, Dispenzieri A, et al. High-dose melphalan and peripheral blood stem cell transplantation for light-chain amyloidosis with cardiac involvement. Blood. Feb 2 2012;119(5):1117-1122. PMID 22147893 
  16. Cibeira MT, Sanchorawala V, Seldin DC, et al. Outcome of AL amyloidosis after high-dose melphalan and autologous stem cell transplantation: long-term results in a series of 421 patients. Blood. Oct 20 2011;118(16):4346-4352. PMID 21828140
  17. Dispenzieri A, Seenithamby K, Lacy MQ, et al. Patients with immunoglobulin light chain amyloidosis undergoing autologous stem cell transplantation have superior outcomes compared with patients with multiple myeloma: a retrospective review from a tertiary referral center. Bone Marrow Transplant. Oct 2013;48(10):1302-1307. PMID 23604010
  18. Girnius S, Seldin DC, Meier-Ewert HK, et al. Safety and efficacy of high-dose melphalan and auto-SCT in patients with AL amyloidosis and cardiac involvement. Bone Marrow Transplant. Dec 9 2013. PMID 24317129
  19. Jimenez-Zepeda VH, Franke N, Reece DE, et al. Autologous stem cell transplant is an effective therapy for carefully selected patients with AL amyloidosis: experience of a single institution. Br J Haematol. Nov 25 2013. PMID 24266428
  20. Kim SJ, Lee GY, Jang HR, et al. Autologous stem cell transplantation in light-chain amyloidosis patients: a single-center experience in Korea. Amyloid. Dec 2013;20(4):204-211. PMID 23914780 
  21. Sanchorawala V, Hoering A, Seldin DC, et al. Modified high-dose melphalan and autologous SCT for AL amyloidosis or high-risk myeloma: analysis of SWOG trial S0115. Bone Marrow Transplant. Nov 2013;48(12):1537-1542. PMID 23852321
  22. Jaccard A, Moreau P, Leblond V, et al. High-dose melphalan versus melphalan plus dexamethasone for AL amyloidosis. N Engl J Med. Sep 13 2007;357(11):1083-1093. PMID 17855669
  23. Parmar S, Kongtim P, Champlin R, et al. Auto-SCT improves survival in systemic light chain amyloidosis: a retrospective analysis with 14-year follow-up. Bone Marrow Transplant. Aug 2014;49(8):1036-1041. PMID 24887378
  24. Wechalekar AD, Hawkins PN, Gillmore JD. Perspectives in treatment of AL amyloidosis. Br J Haematol. Feb 2008;140(4):365-377. PMID 18162121
  25. Gertz MA, Lacy MQ, Dispenzieri A, et al. Trends in day 100 and 2-year survival after auto-SCT for AL amyloidosis: outcomes before and after 2006. Bone Marrow Transplant. Jul 2011;46(7):970-975. PMID 20935685
  26. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Multiple Myeloma (V.1.2015). Available online at: http://www.nccn.org/professionals/physician_gls/PDF/myeloma.pdf,. 2014.
     

     

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  Transplant preparation of hematopoietic progenitor cell; thawing of previously frozen harvest without washing
   38209  ;thawing of perviously frozen harvest, with washing
   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 
  38230 Bone marrow harvesting for transplantation; allogeneic
  38232 Bone marrow harvesting for transplantation; autologous
   38240  Bone marrow or blood-derived peripheral stem-cell transplantation; allogeneic 
   38241  Bone marrow or blood-derived peripheral stem-cell transplantation; autologous 
  38242  ;allogeneic donor lymphocyte infusions
ICD-9 Procedure  41.01  Autologous bone marrow transplant without purging 
  41.02 Allogeneic bone marrow transplant with purging
  41.03 Allogeneic bone marrow transplant without purging
    41.04  Autologous hematopoietic stem-cell transplant without purging
  41.05 Allogeneic hematopoietic stem-cell transplant without purging
  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 273.3 Macroglobulinemia
   277.30-277.39 Amyloidosis code range
HCPCS    Q0083 - Q0085  Chemotherapy administration code range 
   J9000 - J9999  Chemotherapy drug 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) 
ICD-10-CM (effective 10/1/15) E85.0-E85.9 Amyloidosis code range (this policy would exclude E85.3 secondary systemic and E85.4 organ limited as they are not primary systemic)
ICD-10-PCS (effective 10/1/15) 30243G0, 30243X0,
30243Y0
Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list
  07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ Surgical, lymphatic and hemic systems, extraction, bone marrow, code list
Type of Service  Therapy 
Place of Service  Inpatient/Outpatient 

Index

Amyloidosis, High-Dose Chemotherapy
High-Dose Chemotherapy, Primary Amyloidosis
Systemic Amyloidosis, High-Dose Chemotherapy


Policy History

 

Date Action Reason
10/9/03 Add to Therapy section New policy (split amyloidosis and Waldenstrom’s macroglobulinemia from policy No. 8.01.17)
02/25/04 Replace policy New policy statement on primary systemic amyloidosis; policy statement on Waldenstrom’s macroglobulinemia unchanged
05/23/05 Replace policy Policy updated with literature search; no change in policy statement. Reference No. 11 updated.
7/20/06 Replace policy Policy updated with literature search; no change in policy statement. 
09/18/07 Replace policy Policy updated with literature search; references 18 and 19 added. No change in policy statement. Lymphoplasmacytic lymphoma was added as another term used to describe Waldenstrom’s macroglobulinemia.
09/11/08 Replace policy Policy updated with literature search; “high-dose chemotherapy” removed from policy title and policy statements. “Stem-cell transplantation” (SCT) now used instead of “stem-cell support” (SCS) in policy and policy statements. Intent of current policy statements unchanged. References 13, 15-17, 21-24 added; reference 14 updated
08/13/09 Replace policy Policy updated with literature search; reference number 24 updated. No change in policy statements
2/10/11 Replace policy Policy updated with literature search; reference numbers 24 and 25 added, references 26 and 27 updated. Clinical input reviewed. Policy statement changed to indicate autologous SCT may be considered medically necessary as salvage therapy for chemosensitive Waldenstrom macroglobulinemia.
2/09/12 Replace policy Policy updated with literature search; reference 16 added and 21 updated. Policy statements unchanged
02/14/13 Replace policy
Policy updated with literature search; reference 15 added and 20 updated. Policy statements unchanged
2/13/14 Replace policy Policy updated with literature search through December 23, 2013; references 17-21 added and 25 updated. Policy statements unchanged.
2/12/15 Replace policy Policy updated with literature review through December 2, 2014; reference 23 added, and reference 25 updated. Policy statements unchanged.