Anthem Blue Cross Connecticut TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors Form

This document addresses hematopoietic stem cell transplantation as a treatment of germ cell tumors (testicular, mediastinal, retroperitoneal, ovarian). Germ cell tumors are neoplasms developed from the reproductive germ cell line.

Note: For epithelial ovarian carcinoma, see TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors.

Position Statement

Medically Necessary:

A single autologous hematopoietic stem cell transplantation is considered medically necessary as a treatment of primary germ cell tumors* in individuals treated with standard chemotherapy who had one of the following results:

1. A partial response; or
2. Refractory germ cell tumors; or
3. Relapsed disease.

A planned tandem autologous hematopoietic stem cell transplantation is considered medically necessary as a treatment of primary testicular cancer in individuals treated with standard chemotherapy who had one of the following results:

1. A partial response; or
2. Refractory germ cell tumors; or
3. Relapsed disease.

*Note: Ovarian germ cell tumors must be distinguished from the far more common epithelial ovarian cancers. For epithelial ovarian carcinoma, please refer to TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors.

A repeat autologous hematopoietic stem cell transplantation due to primary graft failure or failure to engraft is considered medically necessary.

Investigational and Not Medically Necessary:

A single autologous hematopoietic stem cell transplantation, in lieu of a course of standard chemotherapy, is considered investigational and not medically necessary as initial treatment of poor prognosis germ cell tumors.

A planned tandem autologous hematopoietic stem cell transplantation is considered investigational and not medically necessary as a treatment of all other non-testicular germ cell tumors.

Allogeneic (ablative and non-myeloablative [mini transplant]) hematopoietic stem cell transplantation is considered investigational and not medically necessary as a treatment of germ cell tumors, including but not limited to, use as a therapy after a prior failed high-dose chemotherapy with autologous hematopoietic stem cell support.

A second or repeat autologous hematopoietic transplant due to persistent, progressive or relapsed disease is considered investigational and not medically necessary.

Hematopoietic stem cell harvesting for a future but unscheduled transplant is considered investigational and not medically necessary.