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APPENDIX
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Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Number 8.01.54

Effective Date April 16, 2013

Revision Date(s) 04/08/13; 04/10/12

Replaces N/A

Policy

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Autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia.

Allogeneic hematopoietic stem-cell transplantation is considered investigational to treat Waldenstrom macroglobulinemia.

Related Policies

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7.01.50

Placental and Umbilical Cord Blood as a Source of Stem Cells

8.01.20

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

8.01.21

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

8.01.23

Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer

8.01.28

Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma

8.01.29

Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma

8.01.42

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Policy Guidelines

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In 2003, CPT centralized codes describing allogeneic and autologous HSCT services to the hematology section (38205-38242). 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).

38208 – 38209 describe thawing and washing of cryopreserved cells

38210 – 38214 describe certain cell types being depleted

38215 describes plasma cell concentration

Description

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Hematopoietic Stem-Cell Transplantation

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 “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 a separate medical policy. (See Related Policies)

Background

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 human leukocyte antigens (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 (e.g., 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 non-relapse mortality (NRM) 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 NRM 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.

Waldenstrom Macroglobulinemia

Waldenstrom macroglobulinemia (WM) is a B-cell malignancy that accounts for 1–2% of hematologic malignancies, with an estimated 1,500 new cases annually in the U.S. The median age of WM patients at presentation is 63 to 68 years, with men comprising 55–70% of cases. Median survival of WM ranges from 5 to10 years, with age, hemoglobin concentration, serum albumin level, and beta-2 microglobulin level as predictors of outcome. The Revised European American Lymphoma (REAL) and World Health Organization (WHO) classification, and a consensus group formed at the Second International Workshop on WM recognize WM primarily as a lymphoplasmacytic lymphoma (LPL) with an associated immunoglobulin M (IgM) monoclonal gammopathy. The definition also requires the presence of a characteristic pattern of bone marrow infiltration with small lymphocytes demonstrating plasmacytic differentiation with variable cell surface antigen expression. The Second International Workshop indicated no minimum serum concentration of IgM is necessary for a diagnosis of WM.

Treatment of WM is indicated only in symptomatic patients and should not be initiated solely on the basis of serum IgM concentration. Clinical and laboratory findings that indicate the need for therapy of diagnosed WM include hemoglobin concentration less than 100 g/L; platelet count less than 100 x 109/L; significant adenopathy or organomegaly; symptomatic Ig-related hyperviscosity ( >50 g/L); severe neuropathy; amyloidosis; cryoglobulinemia; cold-agglutinin disease; or evidence of disease transformation. Primary chemotherapeutic options have included alkylating agents (chlorambucil, cyclophosphamide, melphalan), purine analogues (cladribine, fludarabine), and monoclonal antibody agents (rituximab), alone or in various combinations. Plasma exchange is indicated for acute treatment of symptomatic hyperviscosity.

Scope

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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.

Benefit Application

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N/A

Rationale

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A 2002 International Workshop summarized clinical experience (combined n=49) using autologous hematopoietic stem-cell transplantation (HSCT) for Waldenstrom macroglobulinemia (WM). (1) These were all small feasibility studies that reported response rates but lacked data on survival and other long-term outcomes. A total of 9 (18%) achieved complete response (CR) and 39 (80%) achieved partial response (PR), but data on the durability of these responses were unavailable.

A consensus panel from the Second International Workshop on Waldenstrom’s Macroglobulinemia recommended that autologous HSCT may be considered for selected patients with refractory or relapsing disease, but allogeneic transplants should be used only in the context of a clinical trial. (2) Another recent review agreed that the role of autologous HSCT for Waldenstrom macroglobulinemia was not fully defined, although its empirical use might be appropriate for some patients with relapsed or refractory disease. (3) This review also considered allogeneic transplants for Waldenstrom macroglobulinemia to be investigational therapy.

In 2004, a consensus panel from the Third International Workshop on Waldenstrom’s Macroglobulinemia suggested autologous HSCT may be considered for eligible patients with primary refractory or relapsing disease but that allogeneic transplants should be cautiously approached, only in the context of a clinical trial. (4) However, the review article does not cite evidence to support the recommendations. The panelists also concluded that it was not possible to recommend a particular first-line therapeutic approach; rather, the choice should be made on the basis of individual patient considerations. A retrospective Center for International Blood and Marrow Transplant Research (CIBMTR) registry analysis of HSCT (autologous, n=10, allogeneic, n=26) for WM reported 3-year overall survival (OS) rates of 46% (95% confidence interval [CI]: 27–65%) for allogeneic HSCT recipients and 70% (95% CI: 40–93%) for autologous HSCT patients. (5) Although the CIBMTR results appear favorable, it should be noted that patients in this report were heavily pretreated, highly heterogeneous in terms of disease characteristics and risk factors, and received a variety of conditioning regimens, including myeloablative and RIC, between 1986 and 2002. These data, taken together, are insufficient to form conclusions about the potential clinical efficacy of HSCT for WM. Subsequent additional review articles are in general agreement with this position (6,7)

Kyriakou et al. reported on 158 adult patients with WM reported to the European Group for Blood and Marrow Transplantation (EBMT) between January 1991 and December 2005. (8) Median time from diagnosis to autologous HSCT was 1.7 years (range, 0.3 to 20.3 years), 32% of the patients experienced treatment failure with at least 3 lines of therapy, and 93% had sensitive disease at the time of HSCT. Median follow-up for surviving patients was 4.2 years (range: 0.5 to 14.8 years). Nonrelapse mortality (NRM) was 3.8% at 1 year. Relapse rate was 52.1% at 5 years. Progression-free survival (PFS) and OS were 39.7% and 68.5%, respectively, at 5 years and were significantly influenced by number of lines of therapy and chemorefractoriness at HSCT. The authors conclude that autologous HSCT is a feasible procedure in young patients with advanced WM but that it should not be offered to patients with chemoresistant disease and to those who received more than 3 lines of therapy.

Kyriakou and colleagues also reported on a retrospective analysis of a smaller group of patients who had allogeneic HSCT for WM. (9) A total of 86 patients received allogeneic HSCT by using either myeloablative conditioning (MAC; n=37) or reduced-intensity conditioning (RIC; n=49) regimens. The median age was 49 years (range: 23 to 64 years); 47 patients had received 3 or more previous lines of therapy, and 8 patients had experienced failure on a prior autologous HSCT. A total of 59 patients (68.6%) had chemotherapy-sensitive disease at the time of allogeneic HSCT. Median follow-up of the surviving patients was 50 months. The overall response rate was 75.6%. The relapse rates at 3 years were 11% for MAC and 25% for RIC. Overall survival at 5 years was 62% for MAC and 64% for RIC, respectively. The occurrence of chronic graft-versus-host disease (GVHD) was associated with a lower relapse rate. The authors concluded that allogeneic HSCT can induce durable remissions in a selected population of young and heavily pretreated patients who have WM.

Little additional published evidence is available on use of autologous HSCT for WM, as summarized in 2 recent review articles. (10-13) No randomized trials have been reported.

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

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. 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. The input indicated that autologous HSCT may be considered medically necessary as salvage therapy in Waldenstrom macroglobulinemia that is chemosensitive. The input was mixed for use of allogeneic HSCT, with comments about this being performed as part of a clinical trial.

Summary

In summary, based on the literature and clinical input, autologous HSCT may be considered medically necessary as salvage therapy for chemosensitive Waldenstrom macroglobulinemia. Allogeneic HSCT for Waldenstrom macroglobulinemia is considered investigational.

National Comprehensive Cancer Network Guidelines

The 2011 National Comprehensive Cancer Network (NCCN) guidelines indicate that selected cases of Waldenstrom’s macroglobulinemia may be treated with autologous or allogeneic HSCT but the latter only in a clinical trial. (14)

National Cancer Institute Physician Data Query (PDQ®) Database

No current study is specifically focused on HSCT for Waldenstrom’s macroglobulinemia. Five Phase III studies are active that may involve patients with WM (Available online at: http://www.cancer.gov/clinicaltrials/search/results?protocolsearchid=10076025).

References

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  1. Munshi NC, Barlogie B. Role for high-dose therapy with autologous hematopoietic stem cell support in Waldenstrom's macroglobulinemia. Semin Oncol 2003; 30(2):282-5.
  2. Gertz MA, Anagnostopoulos A, Anderson K et al. Treatment recommendations in Waldenstrom's macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia. Semin Oncol 2003; 30(2):121-6.
  3. Ghobrial IM, Gertz MA, Fonseca R. Waldenstrom macroglobulinaemia. Lancet Oncol 2003; 4(11):679-85.
  4. Treon SP, Gertz MA, Dimopoulos M et al. Update on treatment recommendations from the Third International Workshop on Waldenstrom’s macroglobulinemia. Blood 2006; 107(9):3442-6.
  5. Anagnostopoulos A, Hari P, Perez WS et al. Autologous or allogeneic stem cell transplantation in patients with Waldenstrom’s macroglobulinemia. Biol Blood Marrow Transplant 2006; 12(8):845-54.
  6. Fonseca R, Hayman S. Waldenstrom macroglobulinemia. Br J Haematol 2007; 138(6):700-20.
  7. Vijay A, Gertz MA. Waldenstrom macroglobulinemia. Blood 2007; 109(12):5096-103.
  8. Kyriakou C, Canals C, Sibon D et al. High-dose therapy and autologous stem-cell transplantation in Waldenstrom macroglobulinemia: the Lymphoma Working Party of the European Group for Blood and Marrow Transplantation. J Clin Oncol 2010; 28(13):2227-32.
  9. Kyriakou C, Canals C, Cornelissen JJ et al. Allogeneic stem-cell transplantation in patients with Waldenström macroglobulinemia: report from the Lymphoma Working Party of the European Group for Blood and Marrow Transplantation. J Clin Oncol 2010; 28(33):4926-34.
  10. Usmani S, Sexton R, Crowley J et al. Autologous stem cell transplantation as a care option in Waldenstrom's macroglobulinemia. Clin Lymphoma Myeloma Leuk 2011; 11(1):139-42.
  11. Bachanova V, Burns LJ. Hematopoietic cell transplantation for Waldenstrom macroglobulinemia. Bone Marrow Transplant 2012; 47(3):330-6.
  12. Gertz MA, Reeder CB, Kyle RA et al. Stem cell transplant for Waldenstrom macroglobulinemia: an underutilized technique. Bone Marrow Transplant 2012; 47(9):1147-53.
  13. Gertz MA. Waldenstrom macroglobulinemia: 2012 update on diagnosis, risk stratification, and management. Am J Hematol 2012; 87(5):503-10.
  14. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Waldenstrom’s Macroglobulinemia/Lymphoplasmacytic Lymphoma (V.2.2011). Last accessed March 14, 2013.
  15. Reviewed and recommended by OAP on November 17, 2011.
  16. Blue Cross and Blue Shield Association. Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia. Medical Policy Reference Manual, Policy 8.01.54, 2013.

Coding

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Codes

Number

Description

CPT

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 cells; thawing of previously frozen harvest without washing

 

38209

; thawing of previously 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

 

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

ICD-10-CM
(effective 10/1/14)

C88.0

Waldenstrom macroglobulinemia

ICD-10-PCS
(effective 10/1/14)

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

     
     
     
     

HCPCS

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)

Type of Service

Therapy

 

Place of Service

Inpatient/
Outpatient

 

Appendix

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N/A

History

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Date

Reason

07/12/11

Add to Therapy Section - New policy created (Waldenstrom macroglobulinemia removed from original policy No. 8.01.42 [previously combined amyloidosis and Waldenstrom policy]). Policy updated with literature search; reference numbers 8 and 9 added; reference 10 updated. Clinical input reviewed. Policy statement changed to indicate autologous SCT may be considered medically necessary as salvage therapy for chemosensitive Waldenstrom macroglobulinemia.

10/19/11

Codes 38220 and 38221 removed from policy.

11/17/11

  1. and recommended by OAP on November 17, 2011.

01/25/12

Code 32832 added.

02/09/12

CPT code 38204 was removed from the policy.

04/25/12

Replace policy. Policy updated with literature search through mid-January 2012. References 10 and 11 added; reference 12 updated. Policy statements unchanged.

10/01/12

Update Related Policies – Add 8.01.21, 8.01.23, 8.01.28 and 8.01.29; ICD-10 codes are now effective 10/01/2014.

02/01/13

Update Related Policies, change title of policy 8.01.21.

04/16/13

Replace policy. Policy updated with literature search through mid-January 2013. References 10-13 added; reference 14 updated. Policy statements unchanged. The following codes were removed from the policy, as they were not suspending and just informational: HCPCS J9000-J999 and Q0083 – Q0085.

09/30/13

Update Related Policies. Add 8.01.31.

12/06/13

Update Related Policies. Remove 8.01.31 as it was archived.

01/30/14

Update Related Policies. Change title for 8.01.21.


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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