Stem-Cell Transplant for Breast Cancer
© Blue Cross and Blue Shield of Montana
Current Effective Date:
December 27, 2013
Original Effective Date:
February 15, 2012
September 27, 2013
March 22, 2012; September 10, 2013
The use of hematopoietic stem-cell transplantation (HSCT) has been investigated for treatment of patients with breast cancer. Hematopoietic stem cells are infused to restore bone marrow function following cytotoxic doses of chemotherapeutic agents with or without whole body radiation therapy.
Breast cancer comprises several different types that are distinguished mostly by their rate of growth and tendency to spread to other organs. Staging is based on the degree of spread of the disease. The use of high-dose chemotherapy (HDC) and HSCT, instead of standard dose chemotherapy, has been used in an attempt to prolong survival in women with high-risk nonmetastatic and metastatic breast cancer, stage II, stage III and stage IV disease. The stages are defined as follows:
- High-risk stage II - involvement of four or more axillary lymph nodes without metastasis outside the axilla;
- Stage IIIA - presence of fixed axillary lymph nodes, OR primary tumor larger than 5 centimeters with involvement of axillary lymph nodes;
- Stage IIIB - presence of brawny induration of the skin overlying the breast due to involvement of lymphatics (also known as inflammatory breast cancer) OR any size primary tumor, having involvement of ipsilateral internal mammary nodes;
- Stage IV - presence of distant metastases (involvement of the axilla, chest wall, internal mammary nodes or contralateral breast is defined as locoregional disease and does not constitute distant disease).
NOTE: The stage of disease refers to the stage identified at the time of consideration for HDC, and not the stage at the time of the original diagnosis of breast cancer.
Experimental, Investigational and Unproven for all codes. 41.00, 41.01, 41.02, 41.03, 41.04, 41.05, 41.06, 41.07, 41.08, 41.09, 41.91, 99.25, 99.74, 99.79
Experimental, Investigational and Unproven for all codes. 30230G0, 30230G1, 30233G0, 30233G1, 30240G0, 30240G1, 30243G0, 30243G1, 30250G0, 30250G0, 30250G1, 30253G0, 30253G1, 30260G0, 30260G1, 30263G0, 30263G1, 3E03005, 3E03305, 3E04005, 3E04305, 3E05005, 3E05305, 3E06005, 3E06305, 6A550Z2, 6A551Z2, 6A550ZT, 6A550ZV, 6A551ZT, 6A551ZV
36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232, 38240, 38241, 38242, 38243, 81265, 81266, 81267, 81268, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86805, 86806, 86807, 86808, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86828, 86829, 86830, 86831, 86832, 86833, 86834, 86835, 86849, 86950, 86985, 88240, 88241, S2140, S2142, S2150
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||New Policy for BCBSMT. Codes already sent with other Hematopoietic Stem-Cell Transplant policies.|
||Policy updated with literature search; no references added; reference 22 updated. No change to policy statements|
||Policy formatting and language revised. Title changed from "Hematopoietic Stem-Cell Transplantation for Breast Cancer" to "Stem-Cell Transplant for Breast Cancer". Added to the policy statement that tandem or triple stem-cell support, donor leukocyte infusion, hematopoietic progenitor cell boost, and any use of short tandem repeat markers are considered experimental, investigational, and unproven.|