MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Placental and Umbilical Cord Blood as a Source of Stem Cells

Number 7.01.50

Effective Date November 20, 2014

Revision Date(s) 11/10/14; 11/11/13; 12/11/12; 11/10/11; 08/10/10; 12/08/09; 12/11/07; 09/12/03; 04/09/02; 05/05/97

Replaces N/A

Policy

Transplantation of cord blood stem cells from related or unrelated donors may be considered medically necessary in patients with an appropriate indication for allogeneic stem-cell transplant. (See Related Policies).

Transplantation of cord blood stem cells from related or unrelated donors is considered investigational in all other situations.

Collection and storage of cord blood from a neonate may be considered medically necessary when an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the possible need for allogeneic transplant.

Prophylactic collection and storage of cord blood from a neonate may be considered not medically necessary when proposed for some unspecified future use as an autologous stem-cell transplant in the original donor, or for some unspecified future use as an allogeneic stem-cell transplant in a related or unrelated donor.

Related Policies

8.01.15

Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

8.01.17

Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

8.01.21

Allogeneic Hematopoietic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

8.01.22

Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias

8.01.23

Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer

8.01.24

Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults

8.01.25

Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases

8.01.26

Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia

8.01.27

Hematopoietic Stem-Cell Transplantation for Breast Cancer

8.01.28

Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma

8.01.29

Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma

8.01.30

Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia

8.01.511

Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood

8.01.529

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

8.01.530

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

8.01.531

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

8.01.532

Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors

Policy Guidelines

Please refer to the Related Policies section for additional policies for specific conditions/diseases that have patient selection criteria regarding situations for which allogeneic stem-cell transplantation may be considered medically necessary.

Description

This policy addresses the collection, storage, and transplantation of placental/umbilical cord blood (“cord blood”) as a source of stem cells for allogeneic and autologous stem-cell transplantation. Potential indications for use of cord blood are not addressed in this policy; they are included in the disease-specific reference policies. (See Related Policies).

Background

A variety of malignant diseases and nonmalignant bone marrow disorders are treated with myeloablative therapy followed by infusion of allogeneic stem and progenitor cells collected from immunologically compatible donors, either from family members or an unrelated donor identified through a bone marrow donor bank. In some cases, a suitable donor is not found.

Blood harvested from the umbilical cord and placenta shortly after delivery of neonates contains stem and progenitor cells capable of restoring hematopoietic function after myeloablation. This cord blood has been used as an alternative source of allogeneic stem cells. Cord blood is readily available and is thought to be antigenically naive,” thus hopefully, minimizing the incidence of graft-versus-host disease (GVHD) and permitting the broader use of unrelated cord blood transplants. Unrelated donors are typically typed at low resolution for HLA -A and -B and at high resolution only for HLA-DR; HLA matching at 4 of 6 loci is considered acceptable. Under this matching protocol, an acceptable donor can be identified for almost any patient. (1)

Several cord blood banks have now been developed in Europe and in the United States. In addition to obtaining cord blood for specific related or unrelated patients, some cord blood banks are offering the opportunity to collect and store a neonate’s cord blood for some unspecified future use in the unlikely event that the child develops a condition that would require autologous transplantation. In addition, some cord blood is collected and stored from a neonate for use by a sibling in whom an allogeneic transplant is anticipated due to a history of leukemia or other condition requiring allogeneic transplant.

Standards and accreditation for cord blood banks are important for assisting transplant programs in knowing whether individual banks have quality control measures in place to address such issues as monitoring cell loss, change in potency, and prevention of product mix-up.(2) Two major organizations are working toward these accreditation standards; NetCord/FACT and the American Association of Blood Banks (AABB). NetCord, Foundation for the Accreditation of Cellular Therapy (FACT) has developed and implemented a program of voluntary inspection and accreditation for cord blood banking. In September 2012, NetCord and FACT released the fifth edition of their international standards for cord blood banks. (3) The voluntary program includes standards for collection, testing, processing, storage, and release of cord blood products.

Regulatory Status

According to the U.S. Food and Drug Administration (FDA), cord blood stored for potential use by a patient unrelated to the donor meets the definitions of “drug” and “biological products.” As such, products must be licensed under a biologics license application or an investigational new drug application before use. Facilities that prepare cord blood units only for autologous and/or first- or second-degree relatives are required to register and list their products, adhere to Good Tissue Practices issued by the FDA, and use applicable processes for donor suitability determination.4

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

Through the National Marrow Donor Program’s Related Donor Cord Blood Program, eligible families within the U.S. can collect and store their neonate’s cord blood unit free of charge. When the stored unit is transplanted, a fee is charged. A family is considered eligible if:

  • The sibling of the neonate has been diagnosed with a disease treatable by a related cord blood transplant
  • The neonate does not have the same disease as the affected biological sibling (determined after birth)
  • The affected sibling and the neonate have the same biological parents

or if:

  • An affected biological parent is enrolled in a clinical or research trial that would accept a haploidentical, related, allogeneic cord blood unit as a treatment option.

Rationale

This policy was originally based on TEC Assessments in 1996 and 2001, (5, 6) which addressed the use of placental/umbilical cord blood in children and adults, respectively. The policy was updated regularly with searches of the MEDLINE database, most recently through July 21, 2014.

Related Allogeneic Cord Blood Transplant

The first cord blood transplant was a related cord blood transplant for a child with Fanconi anemia; results were reported in 1989.7 At least 60 other cord transplants have subsequently been performed in matched-siblings. The results of these transplants demonstrated that cord blood contains sufficient numbers of hematopoietic stem and progenitor cells to reconstitute pediatric patients. A lower incidence of acute and chronic graft-versus-host disease (GVHD) when cord blood, as compared with bone marrow, was used as the source of donor cells was also observed. (8) This led to the idea that cord blood could be banked and used as a source of unrelated donor cells, possibly without full HLA matching. (9)

Unrelated Allogeneic Cord Blood Transplant

In 1996, outcome data from the first 25 unrelated cord blood transplants completed at Duke University were reported. (10) The authors concluded that cord blood contained sufficient numbers of stem cells and progenitor cells to reconstitute the marrow of children who underwent myeloablative treatments, without full HLA matching between donor and recipient.

Since this time, research has been conducted to study the effectiveness of placental/umbilical cord blood for the treatment of various conditions. The first prospective study of unrelated cord blood transplant was the Cord Blood Transplantation study (COBLT) from 1997 to 2004. COBLT was designed to examine the safety of unrelated cord blood transplantation in infants, children, and adults. In children with malignant and nonmalignant conditions, two-year event-free survival was 55% in children with high-risk malignancies (11) and 78% in children with nonmalignant conditions. (12) Across all groups, the cumulative incidence of engraftment by day 42 was 80%. Engraftment and survival were adversely affected by lower cell doses, pretransplant cytomegalovirus seropositivity in the recipient, non-European ancestry, and higher HLA mismatching. This slower engraftment leads to longer hospitalizations and greater utilization of medical resources. (13) In a retrospective multicenter study of 541 children with acute leukemia, rates of neutrophil recovery at day 60 were statistically different: 96% versus 80% for those receiving unrelated bone marrow and unrelated cord blood, respectively. (14) In the COBLT study, outcomes in adults were inferior to the outcomes achieved in children.

In 2012, Zhang et al. published a meta-analysis of studies comparing unrelated donor cord blood transplantation to unrelated donor bone marrow transplantation in patients with acute leukemia. (15) The authors identified 7 studies with a total of 3,389 patients. Pooled rates of engraftment failure (n=5 studies) were 127 events in 694 patients (18%) in the cord blood transplantation group and 57 events in 951 patients (6%) in bone marrow transplantation patients. The rate of engraftment graft failure was significantly higher in cord blood transplantation recipients (p<0.001). However, rates of acute GVHD were significantly lower in the group receiving cord blood transplantation. Pooled rates of GVHD (n=7 studies) were 397 of 1,179 (34%) in the cord blood group and 953 of 2,189 (44%) in the bone marrow group (p<0.001). Relapse rates, reported in all studies, did not differ significantly between groups. Several survival outcomes including overall survival, leukemia-free survival, and non-relapse mortality favored the bone marrow transplantation group.

A 2014 study by Liu et al. compared outcomes after unrelated donor cord blood transplantation versus matched-sibling donor peripheral blood transplantation. (16) The study included patients age 16 years or older who had hematologic malignancies. A total of 70 patients received unrelated cord blood and 115 patients received HLA-identical peripheral blood stem cells, alone or in combination with bone marrow. Primary engraftment rates were similar in the 2 groups, 97% in the cord blood group and 100% in the peripheral blood stem-cell group. Rates of most outcomes, including grades III to IV acute GVHD and 3-year disease-free survival were also similar between groups. However, the rate of chronic GVHD was lower in the unrelated-donor cord blood group. Specifically, limited or extensive chronic GVHD occurred in 12 of 58 (21%) evaluable patients in the cord blood group and 46 of 109 (42%) evaluable patients in the peripheral blood stem cell group (p=0.005).

In addition to these studies, there have been numerous retrospective and registry studies. These have generally found that unrelated cord blood transplantation is effective in both children and adults with hematologic malignancies and children with a variety of nonmalignant conditions. Most cord blood transplants have been mismatched at one or two HLA loci. For example, a 2007 retrospective comparative analysis from the Center for International Blood and Marrow Transplant Research compared outcomes after unrelated cord blood versus unrelated bone marrow transplant. There were similar five-year leukemia-free survival for those receiving allele-matched marrow and those who received unrelated cord blood with a 1 or 2 antigen mismatch. Moreover, these studies have identified the importance of a minimum cell dose. For example, a 2013 analysis of data from the Korean Cord Blood Registry found that the presence of at least 3.91x105/kg of infused CD34+ cells was significantly associated with overall survival (p=0.03) in unrelated donor cord blood transplants in children and adolescents.17 In other studies, A minimum cell dose of 2.5–3.0 x 107 nucleated cells/kg in the cord blood has been associated with superior clinical outcome.(18-21)

More recently, transplantation of 2 umbilical cord blood units (also known as double unit transplants) have been evaluated as a strategy to overcome cell-dose limitations with 1 cord blood unit in older and heavier patients. Initial experience at the University of Minnesota showed that using 2 units of cord blood for a single transplant in adults improved rates of engraftment and overall survival. (22) A French study evaluating double unit transplants in adults with hematologic malignancies found an engraftment rate of 93% (127/136) and a median overall survival rate of 17.5 months. (23) In 2013, Scaradavou et al. published a study comparing outcomes after transplantation of 1 or 2 cord blood units. (24) Data were from the Center for International Blood and Marrow Transplant Research (CIBMTR) and the U.S.-based National Cord Blood Program. All units used for single transplantation contained a minimum cell dose of 2.5–3.0 X 107 nucleated cells/kg. For the double transplants, the 2 units combined contained more than 2.5–3.0 X 107 nucleated cells/kg, but in about half of cases, individual units contained less than the minimum amount required. In analyses adjusting for factors associated with outcomes, rates of transplantation-related mortality (hazard ratio [HR], 0.91; p=0.63), relapse (HR=0.90, p=0.64) and overall mortality (HR=0.93, p=0.62) were similar in the groups that received single and double transplantations. For patients treated in the earlier period, 2002 to 2004, there was a significantly higher risk of grade 2-4 acute GVHD in recipients of double cord blood units (HR=6.14; 95% confidence interval [CI], 2.54 to 14.87; p<0.001). In the later period, 2004 to 2009, rates of grade 2-4 acute GVHD did not differ significantly between groups (HR=1.69; 95% CI: 0.68 to 4.18; p=0.30).

Autologous Cord Blood Transplant

Data regarding the use of cord blood for autologous stem -cell transplantation are quite limited. However, blood banks are available for collecting and storing a neonate’s cord blood for a potential future use. A position paper from the American Academy of Pediatrics noted that there is no evidence of the safety or effectiveness of autologous cord blood transplantation for treatment of malignant neoplasms. (25) This report comments on evidence demonstrating the presence of DNA mutations in cord blood from children who subsequently develop leukemia. In addition, a survey of pediatric hematologists noted few transplants have been performed using cord blood stored in the absences of a known indication. (26) Thus the practice of collecting and storing cord blood for a potential future use is considered not medically necessary.

Ongoing and Unpublished Clinical Trials

Single Versus Double Umbilical Cord Blood Transplantation in Children With High Risk Leukemia and Myelodysplasia (BMT CTN 0501) (NCT00412360) (27): This RCT is comparing single or double cord blood unit transplantation for treating children with high-risk leukemia and myelodysplasia. The primary study outcome is overall survival. The expected enrollment is 224 patients and the expected date of study completion is May 2015.

Summary of Evidence

Cord blood transplantation offers clear advantages over other sources of allogeneic stem cells; the most significant of these is the ability to perform a successful transplant from an unrelated donor with 1 or 2 HLA mismatches. Cord blood is also more readily available than other sources of stem cells, and generally, can be prepared for clinical use within 1 to 2 weeks. Collection of the cells is painless, which facilitates recruitment and provides for a more ethnically diverse pool. Current limitations include small inventories, units with low cell doses, and too few donors to provide 5 of 6 and 6 of 6 matches for all patients in need. There is some evidence from retrospective studies that double umbilical cord blood transplants may be a safe and effective alternative to single-unit transplants and additional studies are underway. Longer hospital stays and higher utilization of medical resources are a consequence of slower engraftment when cord blood is used. Even with these limitations, cord blood is an important source of stem cells, increasing the access to allogeneic stem-cell transplantation for many patients. Because of these advantages, use of cord blood as a source of stem cells in this situation may be considered medically necessary.

In contrast, the routine collection and storage of cord blood for possible future use is not considered current standard medical care and has not been shown to improve outcomes. As a result, routinely collecting and storing cord blood for a potential future use is considered not medically necessary.

Practice Guidelines and Position Statements

On behalf of the American Society for Blood and Marrow Transplantation, in 2008 Ballen et al. (28) published recommendations related to the banking of umbilical cord blood:

  • Public banking of cord blood is encouraged when possible.
  • Storage of cord blood for autologous (i.e., personal) use is not recommended.
  • Family member banking (collecting and storing cord blood for a family member) is recommended when there is a sibling with a disease that may be successfully treated with an allogeneic transplant.
  • Family member banking on behalf of a parent with a disease that may be successfully treated with an allogeneic transplant is only recommended when there are shared HLA antigens between the parents.

U.S. Preventive Services Task Force Recommendations

Use of placental or umbilical cord blood as a source of stem cells is not a preventive service.

Medicare National Coverage

There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.

References

  1. Godley LA, van Besien K. The next frontier for stem cell transplantation: finding a donor for all. JAMA. Apr 14 2010; 303(14):1421-1422. PMID 20388899
  2. Wall DA. Regulatory issues in cord blood banking and transplantation. Best Pract Res Clin Haematol. Jun 2010; 23(2):171-177. PMID 20837328
  3. NetCord-FACT. International standards for cord blood collection banking and release of information accreditation manual- Fifth Edition. September 2012; http://www.factwebsite.org/uploadedFiles/FACT_News/Draft%205th%20Edition%20NetCord-FACT%20Cord%20Blood%20Accreditation%20Manual.09.04.12.pdf. Accessed October, 2014.
  4. Food and Drug Administration (FDA). Cord Blood Banking: Information for Consumers (July 23, 2012). http://www.fda.gov/biologicsbloodvaccines/resourcesforyou/consumers/ucm236044.htm. Accessed October, 2014.
  5. Blue Cross and Blue Shield Association, Technology Evaluation Center (TEC). Placental and Umbilical Cord Blood as a Source of Stem Cells for Hematopoietic Support. TEC Assessments 1996; Volume 11, Tab 17. PMID
  6. Blue Cross and Blue Shield Association, Technology Evaluation Center (TEC). Transplanting adult patients with hematopoietic stem cells from placental and umbilical cord blood. . Tec Assessments 2001; Volume 16, Tab 17. PMID
  7. Gluckman E, Broxmeyer HA, Auerbach AD, et al. Hematopoietic reconstitution in a patient with Fanconi's anemia by means of umbilical-cord blood from an HLA-identical sibling. N Engl J Med. Oct 26 1989; 321(17):1174-1178. PMID 2571931
  8. Wagner JE, Rosenthal J, Sweetman R, et al. Successful transplantation of HLA-matched and HLA-mismatched umbilical cord blood from unrelated donors: analysis of engraftment and acute graft-versus-host disease. Blood. Aug 1 1996; 88(3):795-802. PMID 8704232
  9. Broxmeyer HE, Douglas GW, Hangoc G, et al. Human umbilical cord blood as a potential source of transplantable hematopoietic stem/progenitor cells. Proc Natl Acad Sci U S A. May 1989; 86(10):3828-3832. PMID 2566997
  10. Kurtzberg J, Laughlin M, Graham ML, et al. Placental blood as a source of hematopoietic stem cells for transplantation into unrelated recipients. N Engl J Med. Jul 18 1996; 335(3):157-166. PMID 8657213
  11. Kurtzberg J, Cairo MS, Fraser JK, et al. Results of the cord blood transplantation (COBLT) study unrelated donor banking program. Transfusion. Jun 2005; 45(6):842-855. PMID 15934981
  12. Martin PL, Carter SL, Kernan NA, et al. Results of the cord blood transplantation study (COBLT): outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with lysosomal and peroxisomal storage diseases. Biol Blood Marrow Transplant. Feb 2006; 12(2):184-194. PMID 16443516
  13. Kurtzberg J. Update on umbilical cord blood transplantation. Curr Opin Pediatr. Feb 2009; 21(1):22-29. PMID 19253461
  14. Rocha V, Cornish J, Sievers EL, et al. Comparison of outcomes of unrelated bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood. May 15 2001; 97(10):2962-2971. PMID 11342418
  15. Zhang H, Chen J, Que W. A meta-analysis of unrelated donor umbilical cord blood transplantation versus unrelated donor bone marrow transplantation in acute leukemia patients. Biol Blood Marrow Transplant. Aug 2012; 18(8):1164-1173. PMID 22289799
  16. Liu HL, Sun ZM, Geng LQ, et al. Similar survival, but better quality of life after myeloablative transplantation using unrelated cord blood vs matched sibling donors in adults with hematologic malignancies. Bone Marrow Transplant. May 19 2014. PMID 24842525
  17. Park M, Lee YH, Kang HR, et al. Unrelated donor cord blood transplantation for non-malignant disorders in children and adolescents. Pediatr Transplant. Mar 2014;18(2):221-229. PMID 24372660
  18. Gluckman E, Rocha V, Boyer-Chammard A, et al. Outcome of cord-blood transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group. N Engl J Med. Aug 7 1997; 337(6):373-381. PMID 9241126
  19. Kurtzberg J, Prasad VK, Carter SL, et al. Results of the Cord Blood Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematologic malignancies. Blood. Nov 15 2008; 112(10):4318-4327. PMID 18723429
  20. Prasad VK, Kurtzberg J. Emerging trends in transplantation of inherited metabolic diseases. Bone Marrow Transplant. Jan 2008; 41(2):99-108. PMID 18176609
  21. Rubinstein P, Carrier C, Scaradavou A, et al. Outcomes among 562 recipients of placental-blood transplants from unrelated donors. N Engl J Med. Nov 26 1998; 339(22):1565-1577. PMID 9828244
  22. Barker JN, Weisdorf DJ, DeFor TE, et al. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood. Feb 1 2005; 105(3):1343-1347. PMID 15466923
  23. Wallet HL, Sobh M, Morisset S, et al. Double umbilical cord blood transplantation for hematological malignancies: a long- term analysis from the SFGM-TC registry. Exp Hematol. Jul 2 2013. PMID 23831606
  24. Scaradavou A, Brunstein CG, Eapen M, et al. Double unit grafts successfully extend the application of umbilical cord blood transplantation in adults with acute leukemia. Blood. Jan 31 2013; 121(5):752-758. PMID 23223509
  25. Lubin BH, Shearer WT. Cord blood banking for potential future transplantation. Pediatrics. Jan 2007; 119(1):165-170. PMID 17200285
  26. Thornley I, Eapen M, Sung L, et al. Private cord blood banking: Experiences and views of pediatric hematopoietic cell transplantation physicians. Pediatrics. Mar 2009; 123(3):1011-1017. PMID 19255033
  27. Sponsored by Medical College of Wisconsin. Single Versus Double Umbilical Cord Blood Transplantation in Children With High Risk Leukemia and Myelodysplasia (BMT CTN 0501) (NCT00412360). Available online at: www.clinicaltrials.gov. Last accessed October 7, 2014.
  28. Ballen KK, Barker JN, Stewart SK, et al. Collection and preservation of cord blood for personal use. Biol Blood Marrow Transplant. Mar 2008; 14(3):356-363. PMID 18275904
  29. Blue Cross and Blue Shield Association (BCBSA) Medical Policy Reference Manual, Placental and Umbilical Cord Blood as a Source of Stem Cells. Medical Policy Reference Manual, Policy 7.01.50, 2014.

Coding

Codes

Number

Description

CPT

38232

Bone marrow harvesting for transplantation; autologous

 

38240

Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic

HCPCS

S2140

Cord blood harvesting for transplantation, allogeneic

 

S2142

Cord blood-derived stem-cell transplantation, allogeneic

 

S2150

Bone marrow or blood-derived stem-cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre-and post-transplant care in the global definition

Type of Service

Surgery/

transplant

 

Place of Service

Inpatient

 

Appendix

N/A

History

Date

Reason

05/05/97

Add to Surgery Section - New Policy

04/09/02

Replace policy - Policy updated and revised based on 2001 TEC Assessment; cord blood as a source of stem cells no longer restricted to children, considered medically necessary in adults.

09/12/03

Replace policy - Policy updated; statement added about storing cord blood stem cells for later possible use as autologous transplant.

06/09/06

Disclaimer and Scope update - No other changes.

12/11/07

Replace policy - Reviewed with literature search; no change to policy statement; references added. Reviewed and recommended by OAP on November 15, 2007.

05/13/08

Cross Reference Update - No other changes

12/08/09

Replace policy - Reviewed with literature search; no change to policy statement; Reviewed by OAP November 2009. Benefit Application language regarding storage added.

08/10/10

Replace policy - Policy updated with literature review and extensive revisions. References 1, 2 and 5-19 have been added. The intent of the policy statements has not changed.

11/10/11

Replace policy – Policy updated with literature review; policy statement unchanged. References 3 and 4 added. Related Policies updated.

01/25/12

Code 38232 added.

09/10/12

Update Related Policy – Remove 7.01.503 as it was deleted; Add 8.01.21 and 8.01.22. ICD-10 codes are now effective 10/01/2014.

10/01/12

Update Related Policies – Add 8.01.20, 8.01.29, 8.01.23, 8.01.27, 8.01.28, 8.01.30.

10/26/12

Update Related Policies. Add 8.01.26.

12/19/12

Replace policy. Policy updated with literature review; policy statements unchanged. References 5, 9-11 added. Add Related Policies 8.01.24, 8.01.31 and 8.01.35.

02/01/13

Update Related Policies, change title of policy 8.01.21.

02/15/13

Update Related Policies, change title of policy 8.01.30.

07/25/13

Update Related Policies. Change title of policy 8.01.35, add 8.01.511.

09/30/13

Update Related Policies. Change title of policy 8.01.31.

12/04/13

Replace policy. Rationale updated based on a literature review through July 25, 2013. References 4, 5, 19, 20, 26, 29, 30 added; others renumbered or removed. Policy statements unchanged.

01/20/14

Update Related Policies. Change title to 8.01.21.

02/27/14

Update Related Policies. Change title to 8.01.30.

03/21/14

Update Related Policies. Add 8.01.15 and delete 8.01.514.

04/18/14

Update Related Policies. Delete 8.01.20 and add 8.01.529.

06/24/14

Update Related Policies. Delete 8.01.35, 8.01.42 and 8.01.54, then add 8.01.530, 8.01.531 and 8.01.532.

11/20/14

Annual Review. Policy updated with literature review through July 21, 2014. Policy statements unchanged. References 4, 16-17, and 23 added. ICD-9 and ICD-10 procedure codes removed; these are not utilized in adjudication of the policy.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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