DESCRIPTION
Hematopoietic progenitor cell (HPC) boost is an infusion of stem cells given to an individual following autologous and allogeneic hematopoietic stem cell transplantation (HSCT). It is intended to restore hematopoiesis or augment poor graft function after hematopoietic stem cell transplantation (HCST). Poor graft function is a severe complication of HSCT and is defined as continued cytopenias and/or transfusion dependence. HPC boost may be taken from a previously cryopreserved cell products or the donor may need to undergo additional evaluation, stem cell mobilization, and cell harvest. There is potential confusion that cell boost is often required when additional conventional chemotherapy is given to treat relapse and reestablish remission after transplantation. Prolonged cytopenias and immunosuppression may result, requiring additional HPC boost that is typically given days to weeks after reinduction chemotherapy.
POLICY
Hematopoietic progenitor cell (HPC) boost is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Hematopoietic progenitor cell (HPC) boost is considered medically appropriate if ALL the following are met:
Treatment is following autologous and allogeneic hematopoietic stem cell transplantation (HSCT) and ANY ONE of the following are met:
To promote engraftment
Enhancement of chimerism (two different sets of DNA) when studies reveal < 100% donor cells
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Although there isn’t any strong evidence to support Hematopoietic Progenitor Cell (HPC) Boost, several prospective and retrospective clinical trials demonstrate beneficial effects of HPC boost after hematopoietic stem cell transplantation (HSCT). The evidence is sufficient to determine the effects of the technology on net health outcomes.
SOURCES
Ghobadi, A., Fiala, M.A., Ramsingh, G., Gao, F., Abboud, C.N., Stockerl-Goldstein, K., et al. (2017). Fresh or cryopreserved CD34+-selected mobilized peripheral blood stem and progenitor cells for the treatment of poor graft function following allogeneic hematopoietic cell transplantation. Biology of blood and marrow transplantation: Journal of the American Society for Blood and Marrow Transplantation, 23 (7), 1072-1077. (Level 4 evidence)
Klyuchnikov, E., El-Cheikh, J., Sputtek, A., Lioznov, M., Calmels, B., Furst, S., et al. (2014). CD34(+)-selected stem cell boost without further conditioning for poor graft function after allogeneic stem cell transplantation in patients with hematological malignancies. Biology of blood and marrow transplantation: Journal of the American Society for Blood and Marrow Transplantation, 20 (3), 382-386. (Level 4 evidence)
Mainardi, C., Ebinger, M., Enkel, S., Feuchtinger, T., Teltschik, H., Eyrich, M., et al. (2018). CD34+ selected stem cell boosts can improve poor graft function after paediatric allogeneic stem cell transplantation. British Journal of Haematology, 180 (1), 90-99. (Level 4 evidence)
National Comprehensive Cancer Network (2023, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Chronic myeloid leukemia (v.1.2024). Retrieved November 29, 2023, from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network (2023, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Acute myeloid leukemia (v.6.2023). Retrieved November 29, 2023, from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network (2023, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hematopoietic cell transplantation (HCT) (v.3.2023). Retrieved November 29, 2023, from the National Comprehensive Cancer Network.
Shahzad, M., Siddiqui, R.S., Anwar, I., Chaudhary, S.G., Ali, T., Naseem M., et al. (2021). Outcomes with CD34-selected stem cell boost for poor graft function after allogeneic hematopoietic stem cell transplantation: A systematic review and meta-analysis. Transplantation and Cellular Therapy, 27 (10), 877.e1-877.e8. (Level 1 evidence) (Level 1 evidence)
ORIGINAL EFFECTIVE DATE: 3/2/2023
MOST RECENT REVIEW DATE: 1/11/2024
ID_BT
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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