![]() ![]() In the absence of an institution's selection criteria, Aetna considers a repeat allogeneic hematopoietic cell transplantation (ablative or mini-allograft) medically necessary when the first allogeneic hematopoietic cell transplantation was unsuccessful due to primary graft failure or failure to engraft or for persons who have relapsed after a prior hematopoietic cell transplantation.Īetna considers a repeat allogeneic hematopoietic cell transplantation (ablative or mini-allograft) experimental and investigational for members with persistent or progressive AML disease who have not been remission because its effectiveness for this indication has not been established. Primary refractory AML (i.e., leukemia that does not achieve a complete remission after conventional dose chemotherapy)Īetna considers a repeat allogeneic hematopoietic cell transplantation (ablative or mini-allograft) medically necessary for the treatment of AML when members meet the transplanting institution's selection criteria.Poor-risk to intermediate-risk AML in remission or. ![]() Members who have relapsed following a prior autologous hematopoietic cell transplantation and who are medically able to tolerate the procedure or.In the absence of an institution's selection criteria, Aetna considers allogeneic hematopoietic cell transplantation for the treatment of AML in any one of the following indications: In the absence of an institution's selection criteria, Aetna considers autologous hematopoietic cell transplantation medically necessary for the treatment of AML for any indication (e.g., first or second remission or relapsed AML if responsive to intensified induction chemotherapy) except as first-line treatment.Īetna considers allogeneic hematopoietic cell transplantation (allo-HSCT) (ablative or mini-allograft) medically necessary for the treatment of AML when members meet the transplanting institution's selection criteria. Note: Persons with persistent disease should not be candidates for a mini-allograft transplant.Īetna considers autologous hematopoietic cell transplantation experimental and investigational for ALL because its effectiveness has not been established.Īetna considers tandem (also known as sequential) transplants experimental and investigational for the treatment of ALL because their effectiveness for this indication has not been established.Īetna considers autologous hematopoietic cell transplantation medically necessary for the treatment of acute myelogenous leukemia (AML) when members meet the transplanting institution's selection criteria. In the absence of an institution's selection criteria, Aetna considers allogeneic hematopoietic cell transplantation medically necessary for the treatment of ALL, including primary refractory ALL (i.e., leukemia that does not achieve a complete remission after conventional dose chemotherapy), except for members in refractory relapse, defined as persons in relapse who are unresponsive to 3 or more months of adequate chemotherapy.Īetna considers non-myeloablative allogeneic hematopoietic cell transplantation, also known as mini-allograft or reduced intensity conditioning transplant, medically necessary for the treatment of ALL for members with no persistent disease who meet all of the selection criteria above. ![]() Number: 0640 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background ReferencesĪetna considers allogeneic hematopoietic cell transplantation medically necessary for the treatment of acute lymphocytic leukemia (ALL) when members meet the transplanting institution's selection criteria. ![]()
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