Related Medicare Advantage Medical/Pharmacy Coverage Policies

None

Related Documents

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.

Type

Title

ID Number

Jurisdiction Medicare Applicable States/Territories

• Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

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NCD - Stem Cell Transplantation - 110.23

LCD LCA - Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin | and Non-Hodgkin Lymphoma with B-cell or T-cell Origin - L39477 A59259 - J5 — 38 Wisconsin Physicians Service Insurance Corporation - AL, AK, AZ, AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MS, MO, MT, NE, NH, NJ, NM, NC, NK, OH, OK, OR, PA, RI, SC, TN, TX, UT, VT, VA, WI, WY

LCD LCA - Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin - 139434 59215 — - J15 - CGS Administrators, LLC (Part A/B MAC) - KY. OH '

LCD LCA - Allogeneic Hematopoietic Cell . . Transplantation for Primary Refractory or Relapsed Hodgkin . and Non-Hodgkin Lymphoma with B-cell or T-cell Origin - L36396 A59175 139398 A59177 —— - JE -—JF Noridian Healthcare Solutions, LLC - CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR. SD. UT, WA yer ' Wy

LCA - Transplantation stem cell - AS52879 - J6 - National Government Services, Inc. (Part A/B MAC) JK - National Government Services, Inc. (Part - IL, MN, WI CT, NY, ME, MA, NH, RI, VT)

JK - National Government Services, Inc. (Part A/B MAC LCD LCA Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin - L39513 A59311 - J6 - National Government Services, Inc. (Part A/B MAC) - IL, MN, WI Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

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LCD LCA - Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin - L39270 A59042 - JJ - JM - Palmetto GBA (Part A/B MAC) - AL, GA, TN, NC, SC, VA, WV

Description

Allogeneic bone marrow transplants (BMT) or myeloablative transplants are procedures in which healthy marrow is taken from a matched (related or unrelated) donor and transplanted into the individual after high-dose chemotherapy and/or radiation.

Autologous BMT involves taking the marrow from an affected individual and purging it. After the marrow is purged with chemicals to remove any malignant cells that may be present, it is preserved in a frozen state until needed. Following high-dose chemotherapy and/or radiation therapy, which destroys the remaining marrow, the stored marrow is thawed and transplanted back into the treated individual via intravenous infusion.

Mini transplants or nonmyeloablative transplants are types of allogeneic transplants. This approach involves administering low doses of chemotherapy and/or radiation therapy followed by an infusion of peripheral blood stem cells from a matched (related or unrelated) donor. The primary goal is to achieve graft versus tumor effect. These interventions usually occur after initial attempts of therapy have failed.

It is also used for an individual who may not be able to tolerate a myeloablative transplant. Tumor cell death is not the goal of chemotherapy in this situation; the goal is adequate immunosuppression for engraftment and the creation of room in the marrow for engraftment.

Peripheral stem cell transplants (PSCT) are procedures in which stem cells are taken directly from the blood stream instead of using bone marrow. Both allogeneic and autologous transplants can be performed using peripheral stem cells. Peripheral stem cells may also be utilized to supplement a BMT.

Syngeneic transplants are types of allogeneic transplants in which the donor is an identical twin with identical tissue types. This is a rare type of transplant since few people are identical twins. The advantage of this type of transplant is that graft-versus-host disease is not a problem, however, it does not destroy any remaining cancer cells.

Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

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Tandem transplants are types of autologous transplants in which an individual receives two sequential courses of high-dose chemotherapy with a stem cell transplant. Typically, the two courses are given several weeks to several months apart.

Umbilical cord blood transplants are procedures in which umbilical cord blood from a matched (related or unrelated) donor newborn that is rich in stem cells is used as the donor source for a transplant.

Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

Please refer to the above CMS guidance for stem cell transplants.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the criteria contained in the following:

Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage