This Policy version was replaced on October 28, 2024. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-management, select 'See Medical and Behavioral Health Policies', then 'Blue Cross and Blue Shield of Minnesota Medical and Behavioral Health Policies'. This will bring up the Medical Policy search screen. Enter the policy number without the version number (last three digits). 

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). The cells can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates.

Multiple Myeloma

Multiple myeloma is a systemic malignancy of plasma cells that represents approximately 10% of all hematologic cancers. It is treatable but rarely curable. At the time of diagnosis most patients have generalized disease and the selection of treatment is influenced by patient age, general health, prior therapy and the presence of complications of the disease.

Multiple myeloma (MM) is staged by estimating tumor mass, based on various clinical parameters, such as hemoglobin, serum calcium, number of lytic bone lesions and the presence or absence of renal failure. MM usually evolves from an asymptomatic premalignant stage (termed "monoclonal gammopathy of undetermined significance" or MGUS). Treatment is usually reserved for patients with symptomatic disease (i.e., progressive myeloma). Asymptomatic patients are generally observed, as there is little evidence that early treatment of asymptomatic MM prolongs survival when compared to therapy delivered at the time of symptoms or end-organ damage. In some patients, an intermediate asymptomatic but more advanced premalignant stage is recognized, and referred to as smoldering MM. The overall risk of disease progression from smoldering to symptomatic MM is 10% per year for the first five years, approximately 3% per year for the next 5 years, and 1% for the next 10 years.

Plasma cell leukemia (PCL) is a rare and aggressive form of multiple myeloma characterized by high levels of plasma cells circulating in the peripheral blood that can be detected on conventional peripheral blood smear examination.

POEMS Syndrome

The POEMS syndrome (polyradiculoneuropathy, organomegaly, multiple endocrinopathies, monoclonal protein, and skin changes) is a rare paraneoplastic disorder secondary to a plasma cell dyscrasia. The condition may also be referred to as osteosclerotic myeloma, Crow-Fukase syndrome, or Takasuki syndrome. Other characteristic features of this syndrome include papilledema, extravascular volume overload, sclerotic bone lesions and thrombocytosis. Treatment of POEMS syndrome is based on whether the patient has limited or widespread disease. Radiation therapy is typically used in patients with limited disease, while systemic therapy is recommended for patients with disseminated bone marrow involvement or diffuse sclerotic bone lesions. Autologous HSCT is considered a treatment option for patients with disseminated POEMS syndrome.

Definitions

Dyscrasia: Disease or disorder of the blood.

Myeloablation: The severe or complete depletion of bone marrow cells, resulting from administration of high doses of chemotherapy or radiation therapy prior to bone marrow transplantation.

Tandem stem cell transplantation: Involves a planned second transplant, within six months of the first transplant.

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 nonrelapse mortality (NRM) in the period during which the beneficial graft versus malignancy (GVM) effect of allogeneic transplantation develops. 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) regimen.

I.    Hematopoietic Stem Cell Transplantation (HSCT) for Multiple Myeloma

• Autologous HSCT (i.e., single, tandem, or second [salvage]) may be considered MEDICALLY NECESSARY AND APPROPRIATE to treat multiple myeloma.
• Tandem transplantation with an initial round of autologous HSCT followed by allogeneic HSCT using a reduced-intensity conditioning (RIC) regimen may be considered MEDICALLY NECESSARY AND APPROPRIATE to treat newly diagnosed multiple myeloma patients.
• Allogeneic HSCT, myeloablative or nonmyeloablative, as upfront therapy of newly diagnosed multiple myeloma or as salvage therapy, is considered EXPERIMENTAL/INVESTIGATIVE.

II.   Hematopoietic Stem Cell Transplantation (HSCT) for POEMS Syndrome

• Autologous HSCT (single transplant) may be considered MEDICALLY NECESSARY AND APPROPRIATE to treat disseminated POEMS syndrome (i.e., disseminated bone marrow involvement or diffuse sclerotic bone lesions).
• Tandem autologous HSCT is considered EXPERIMENTAL/INVESTIGATIVE in the treatment of POEMS syndrome.
• Allogeneic HSCT (i.e., myeloablative and nonmyeloablative) is considered EXPERIMENTAL/INVESTIGATIVE in the treatment of POEMS syndrome.

Documentation Submission:

Link to Transplant Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2022-06/x16519r04-transplant-prior-authorization-request-form.pdf