R414-10A-9. Hematopoietic Stem Cell Transplantation (HSCT), Covered Services and Requirements

  (1) Allogeneic and syngeneic hematopoietic stem cell transplantation may be approved only when the patient has a suitable HLA-matched donor and one of the covered conditions is present.

  (a) A search of related family members, unrelated persons, or both to find a suitable donor is a covered service.

  (2) Patient must have adequate marrow and lack of marrow involvement of primary malignancy if autologous transplant.

  (3) Patient must be free from any active infection.

  (4) Allogeneic Hematopoietic Stem Cell Transplantation (ASCT) is covered for:

  (a) Leukemia, leukemia in remission, or aplastic anemia; or

  (b) Severe Combined Immunodeficiency Disease (SCID) and for the treatment of Wiskott-Aldrich syndrome.

  (5) Autologous Hematopoietic Stem Cell Transplantation (AuSCT) is covered for:

  (a) Acute leukemia in remission with a high probability of relapse and has no Human Leucocyte Antigens (HLA)-matched;

  (b) Resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response;

  (c) Recurrent or refractory neuroblastoma; and

  (d) Advanced Hodgkin's disease with failed conventional therapy and has no HLA-matched donor.

  (e) Single AuSCT is only covered for Durie-Salmon Stage II or III that fit the following requirements:

  (i) Newly diagnosed or responsive multiple myeloma. This includes those patients with previously untreated disease, those with at least a partial response to prior chemotherapy (defined as a 50 percent decrease either in measurable paraprotein (serum, urine or both) or in bone marrow infiltration, sustained for at least one month), and those in responsive relapse; and

  (ii) adequate cardiac, renal, pulmonary, and hepatic function.

  (f) When recognized clinical risk factors are employed to select patients for transplantation, High Dose Melphalan (HDM) together with AuSCT is medically reasonable and necessary for any age group with primary Amyloid Light (AL) chain amyloidosis who meet the following criteria:

  (i) Amyloid deposition in two or fewer organs; and

  (ii) Cardiac left ventricular Ejection Fraction (EF) greater than 45 percent.