Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

BlueCross BlueShield of Tennessee Medical Policy Manual

DESCRIPTION

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 individuals who receive bone-marrow-toxic doses of cytotoxic drugs with or without whole-body radiation therapy. Autologous stem cell transplantation refers to the harvesting of bone marrow from the transplant recipient (autologous), usually from the iliac crest, or from the peripheral blood using a pheresis procedure. The harvested cells are then re-administered to the same individual.

Astrocytomas and Gliomas

Astrocytomas and Gliomas arise from glial cells. They are sometimes called gliomas, anaplastic astrocytomas, glioblastoma multiforme, or oligodendroglioma. Diffuse fibrillary astrocytomas are the most common type of brain tumor in adults. These tumors are classified histologically into 3 grades of malignancy: Grade II astrocytoma, grade III anaplastic astrocytoma, and grade IV glioblastoma multiform. Glioblastoma multiforme is the most malignant stage of astrocytoma. Oligodendrogliomas are diffuse neoplasms that are clinically and biologically most closely related to diffuse fibrillary astrocytomas. However, these tumors generally have better prognoses than diffuse astrocytomas.

POLICY

Autologous hematopoietic stem-cell transplantation for the treatment of malignant astrocytomas and gliomas (e.g., glioblastoma multiforme and oligodendroglioma) is considered investigational.

See also:

IMPORTANT REMINDERS

Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

No conclusions can be drawn regarding the health outcomes for these individuals due to a lack of any well-designed randomized controlled trials and studies in peer review journals regarding autologous hematopoietic stem-cell transplantation (HSCT) for individuals with astrocytomas or gliomas.

SOURCES

Abrey, L. E., Childs, B. H., Paleologos, N., Kaminer, L., Rosenfeld, S., Salzman, D., et al. (2006). High-dose chemotherapy with stem cell rescue as initial therapy for anaplastic oligodendroglioma: Long-term follow-up. Neuro-Oncology, 8 (2), 183-188. (Level 2 Evidence - Independent study)

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2012). Autologous hematopoietic stem-cell transplantation for malignant astrocytomas and gliomas (8.01.31).Retrieved November 2, 2012 from BlueWeb. (12 articles and/or guidelines reviewed)

Complete Guide to Medicare Coverage Issues [Computer software]. (2012, April). Stem cell transplantation (NCD 110.8.1, p. 2-51 - 2.53). Ingenix.

Finlay, J. L., Dhall, G., Boyett, J. M., Dunkel, I. J., Gardner, S. L., Goldman, S., et al. Myeloablative chemotherapy with autologous bone marrow rescue in children and adolescents with recurrent malignant astrocytoma: Outcome compared with conventional chemotherapy: A report from the Children's Oncology Group. Pediatric Blood & Cancer, 51 (6), 806-811. (Level 2 Evidence - Independent study)

National Comprehensive Cancer Network. (2012, February). NCCN clinical practice guidelines in oncology™. Central nervous system cancers - V.2.2012. Retrieved Novemberber 2, 2012 from http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf.

Sathornsumetee, S., Rich, J. N., & Reardon, D. A. (2007). Diagnosis and treatment of high-grade astrocytoma. Neurologic Clinics, 25 (4), 1111-1139.

Stupp, R., & Roila, F. (2009). Malignant glioma: ESMO clinical recommendations for diagnosis, treatment and follow-up. Annals of Oncology, 20 (Suppl. 4), 126-128.

ORIGINAL EFFECTIVE DATE: 4/14/2011

MOST RECENT REVIEW DATE: 12/13/2012

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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