150 Hematopoietic Stem Cell Transplantation for ... - AAPC

Medical Policy Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia

Table of Contents

Policy: Commercial Policy: Medicare Authorization Information

Coding Information Description Policy History

Information Pertaining to All Policies References

Policy Number: 150

BCBSA Reference Number: 8.01.26

Related Policies

None

Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members

Allogeneic hematopoietic stem-cell transplantation (HSCT) using a myeloablative conditioning regimen may be MEDICALLY NECESSARY to treat: Poor- to intermediate-risk Acute Myeloid Leukemia (AML) in remission AML that is refractory to, or relapses following, standard induction chemotherapy, or AML in patients who have relapsed following a prior autologous HSCT and are medically able to

tolerate the procedure.

Allogeneic HSCT using a reduced-intensity conditioning regimen as a treatment of AML may be MEDICALLY NECESSARY in patients who are in complete marrow and extramedullary remission, and who for medical reasons would be unable to tolerate a myeloablative conditioning regimen.

Autologous HSCT may be MEDICALLY NECESSARY to treat AML in first or second remission or relapsed AML if responsive to intensified induction chemotherapy.

Prior Authorization Information Commercial Members: Managed Care (HMO and POS)

Prior authorization is required.

Commercial Members: PPO, and Indemnity

Prior authorization is required.

Medicare Members: HMO BlueSM

Prior authorization is required.

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Medicare Members: PPO BlueSM

Prior authorization is required.

CPT Codes / HCPCS Codes / ICD-9 Codes

The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

CPT Codes

CPT codes: 38204 38205

38206

38207 38208

38209

38210

38211 38212 38213 38214 38215

38220 38232 38241

Code Description Management of recipient hematopoietic cell donor search and cell acquisition Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest without washing Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing Transplant preparation of hematopoietic progenitor cells; specific cell depletion with harvest, T-cell depletion Transplant preparation of hematopoietic progenitor cells; tumor-cell depletion Transplant preparation of hematopoietic progenitor cells; red blood cell removal Transplant preparation of hematopoietic progenitor cells; platelet depletion Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer Bone marrow; aspiration only Bone marrow harvesting for transplantation; autologous Hematopoietic progenitor cell (HPC); autologous transplantation

HCPCS codes:

HCPCS codes: S2140 S2142 S2150

Code Description Cord blood harvesting for transplantation; allogeneic Cord blood derived stem-cell transplantation, allogeneic 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-9 Diagnosis Codes

ICD-9-CM

Code Description

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diagnosis codes: 205.00 205.01 205.02

Acute myeloid leukemia, without mention of having achieved remission Acute myeloid leukemia, in remission Acute myeloid leukemia, in relapse

ICD-9 Procedure Codes

ICD-9-CM procedure codes: 41.00 41.01 41.02 41.03 41.04 41.05 41.06 41.07 41.08 41.09

Code Description Bone marrow transplant, not otherwise specified Autologous bone marrow transplant without purging Allogeneic bone marrow transplant with purging Allogeneic bone marrow transplant without purging Autologous hematopoietic stem cell transplant without purging Allogeneic hematopoietic stem cell transplant without purging Cord blood stem cell transplant Autologous hematopoietic stem cell transplant with purging Allogeneic hematopoietic stem cell transplant with purging Autologous bone marrow transplant with purging

ICD-10 Diagnosis Codes

ICD-10-CM Diagnosis codes: C92.00 C92.01 C92.02 C92.40 C92.41 C92.42 C92.50 C92.51 C92.52 C92.60 C92.61 C92.62 C92.A0

Code Description Acute myeloblastic leukemia, not having achieved remission Acute myeloblastic leukemia, in remission Acute myeloblastic leukemia, in relapse Acute promyelocytic leukemia, not having achieved remission Acute promyelocytic leukemia, in remission Acute promyelocytic leukemia, in relapse Acute myelomonocytic leukemia, not having achieved remission Acute myelomonocytic leukemia, in remission Acute myelomonocytic leukemia, in relapse Acute myeloid leukemia with 11q23-abnormality not having achieved remission Acute myeloid leukemia with 11q23-abnormality in remission Acute myeloid leukemia with 11q23-abnormality in relapse Acute myeloid leukemia with multilineage dysplasia, not having achieved remission

C92.A1 C92.A2

Acute myeloid leukemia with multilineage dysplasia, in remission Acute myeloid leukemia with multilineage dysplasia, in relapse

ICD-10 Procedure Codes

ICD-10-PCS procedure codes: 30233G0

30233G1

Code Description Transfusion of Autologous Bone Marrow into Peripheral Vein, Percutaneous Approach Transfusion of Nonautologous Bone Marrow into Peripheral Vein, Percutaneous Approach

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30233X1

30233Y0

30233Y1 30243G0 30243G1 30243X1

30243Y0

30243Y1 30263G0 30263G1

30263X1

30263Y0

30263Y1 3E03305 3E04305 3E05305 3E06305

Transfusion of Nonautologous Cord Blood Stem Cells into Peripheral Vein, Percutaneous Approach Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach Transfusion of Nonautologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous Approach Transfusion of Nonautologous Bone Marrow into Central Vein, Percutaneous Approach Transfusion of Nonautologous Cord Blood Stem Cells into Central Vein, Percutaneous Approach Transfusion of Autologous Hematopoietic Stem Cells into Central Vein, Percutaneous Approach Transfusion of Nonautologous Hematopoietic Stem Cells into Central Vein, Percutaneous Approach Transfusion of Autologous Bone Marrow into Central Artery, Percutaneous Approach Transfusion of Nonautologous Bone Marrow into Central Artery, Percutaneous Approach Transfusion of Nonautologous Cord Blood Stem Cells into Central Artery, Percutaneous Approach Transfusion of Autologous Hematopoietic Stem Cells into Central Artery, Percutaneous Approach Transfusion of Nonautologous Hematopoietic Stem Cells into Central Artery, Percutaneous Approach Introduction of Other Antineoplastic into Peripheral Vein, Percutaneous Approach Introduction of Other Antineoplastic into Central Vein, Percutaneous Approach Introduction of Other Antineoplastic into Peripheral Artery, Percutaneous Approach Introduction of Other Antineoplastic into Central Artery, Percutaneous Approach

Description

Hematopoietic stem-cell transplantation (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 na?ve and thus are associated with a lower incidence of rejection or graft-versus-host disease.

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.

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.

Acute myeloid leukemia (AML, or sometimes called "acute nonlymphocytic leukemia") refers to a set of leukemias that arise from a myeloid precursor in the bone marrow. AML is characterized by proliferation of myeloblasts, coupled with low production of mature red blood cells, platelets, and often nonlymphocytic white blood cells (granulocytes, monocytes).

Summary

A substantial body of published evidence supports the use of allogeneic HSCT as consolidation treatment for AML patients in CR1 who have intermediate- or high-risk disease and a suitable donor; this procedure is not indicated for patients in CR1 with good-risk AML. Data also support the use of

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allogeneic HSCT for patients in CR2 and beyond who are in chemotherapy-induced remission and for whom a donor is available. Allogeneic HSCT is a consolidation option for those with primary refractory or relapsed disease who can be brought into remission once more with intensified chemotherapy and who have a donor. For patients who are in remission but don't have a suitable donor, evidence supports the use of autologous HSCT in consolidation; this procedure is not an option for those who are not in remission. Allogeneic HSCT using RIC is supported by evidence for use in patients who otherwise would be candidates for an allogeneic transplant, but who have comorbidities that preclude use of a myeloablative procedure. These conclusions are generally affirmed in a recent systematic review and analysis of published international guidelines and recommendations, including those of the European Group for Blood and Marrow Transplantation (EBMT), the American Society for Blood and Marrow Transplantation (ASBMT), the British Committee for Standards in Hematology (BCSH), the National Comprehensive Cancer Network, (NCCN), and the specific databases of the National Guideline Clearinghouse and the Guideline International Network database. (28)

Policy History

Action

Date

6/2014

Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015.

12/2013

New references from BCBSA National medical policy.

12/2012

Updated to add new CPT code 38243

11/2011-

Medical policy ICD 10 remediation: Formatting, editing and coding updates.

4/2012

No changes to policy statements.

7/2011

Reviewed - Medical Policy Group - Hematology and Oncology.

No changes to policy statements.

9/2010

Reviewed - Medical Policy Group - Hematology and Oncology.

No changes to policy statements.

9/1/2009

New policy, effective 9/1/2009, describing covered and non-covered indications.

Information Pertaining to All Blue Cross Blue Shield Medical Policies

Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Hamadani M, Mohty M, Kharfan-Dabaja MA. Reduced-intensity conditioning allogeneic hematopoietic cell transplantation in adults with acute myeloid leukemia. Cancer Control 2011; 18(4):237-45.

2. Yanada M, Matsuo K, Emi N et al. Efficacy of allogeneic hematopoietic stem cell transplantation depends on cytogenetic risk for acute myeloid leukemia in first disease remission: a metaanalysis. Cancer 2005; 103(8):1652-8.

3. Greer JP FJ, Rodgers GM, et al., ed Acute myeloid leukemia in adults . Philadelphia: Lippincott Williams & Wilkins; 2009. Wintrobe's Cliniacl Hematology.

4. Hamadani M, Awan FT, Copelan EA. Hematopoietic stem cell transplantation in adults with acute myeloid leukemia. Biol Blood Marrow Transplant 2008; 14(5):556-67.

5. Deschler B, de Witte T, Mertelsmann R et al. Treatment decision-making for older patients with high-risk myelodysplastic syndrome or acute myeloid leukemia: problems and approaches. Haematologica 2006; 91(11):1513-22.

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