BlueCross and BlueShield of Montana Medical Policy/Codes
Stem-Cell Transplant for Epithelial Ovarian Cancer
Chapter: Medicine: Treatments
Current Effective Date: October 25, 2013
Original Effective Date: May 03, 2012
Publish Date: October 25, 2013
Revised Dates: September 25, 2013
Description

The use of hematopoietic stem-cell transplantation (HSCT) has been investigated for treatment of patients with epithelial ovarian cancer. Hematopoietic stem cells are infused to restore bone marrow function following cytotoxic doses of chemotherapeutic agents with or without whole body radiation therapy.

Several different types of malignancies can arise in the ovary; epithelial carcinoma is the most common. Epithelial ovarian cancer is the fifth most common cause of cancer and fourth most common cause of cancer deaths in women; it accounts for 4% of all cancers in women. New cases and deaths from ovarian cancer in the United States in 2012 are estimated at 22,280 and 15,500, respectively. (1) Most ovarian cancer patients present with widespread disease, and yearly mortality is approximately 65% of the incidence rate. (1)

Epithelial ovarian cancer must be distinguished from the much less common germ cell tumor of the ovary. All stages of ovarian cancer are first treated with cytoreductive surgery, including bilateral salpingo-oophorectomy and total abdominal hysterectomy. While this may be sufficient treatment for cases confined to the ovary, typically intraperitoneal spread is identified; therefore, cytoreductive surgery is commonly followed by chemotherapy. (2, 3) Approximately 75% of patients present with International Federation of Gynecology and Obstetrics (FIGO) stage III or IV ovarian cancer and are treated with the combination of paclitaxel and a platinum analog being the preferred regimen for newly diagnosed advanced disease. (3, 4) The use of platinum and taxanes has improved progression-free survival (PFS) and overall survival (OS) rates in advanced disease to 16–21 months and 32–57 months, respectively. (4) However, most of these women develop recurrences and die of the disease as chemotherapy drug resistance leads to uncontrolled cancer growth. (3)

High-dose chemotherapy (HDC) has been investigated as a way to overcome drug resistance. However, the frequent recurrence of ovarian cancer has prompted interest in high-dose chemotherapy and autologous stem-cell support (HDC/AuSCS). A variety of patient groups have been studied as follows to:

  • Consolidate remission after initial treatment;Treat relapse after a durable response to platinum-based chemotherapy;
  • Treat tumors that relapsed after less than six months;Treat refractory tumors.
Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Coverage of, evaluation for, and subsequent single treatment by stem-cell transplant (SCT) (using bone marrow, peripheral blood, or umbilical cord blood as a stem-cell source), derived from a specific donor category, and following a chemotherapy regimen for treatment of epithelial ovarian cancer is identified in the grid below.

NOTE: SCT may be known by different terminology and used interchangeably. Hereinafter, SCT will be known as stem-cell support (SCS) throughout the balance of this medical policy. 

Allogeneic

Is considered experimental, investigational and unproven for epithelial ovarian cancer.

Autologous

Is considered experimental, investigational and unproven for epithelial ovarian cancer.

Tandem or Triple Stem-Cell Support

Is considered experimental, investigational and unproven for epithelial ovarian cancer.

Donor Leukocyte Infusion

Is considered experimental, investigational and unproven for epithelial ovarian cancer.

Hematopoietic Progenitor Cell Boost (Stem-Cell Boost)

Is considered experimental, investigational and unproven for epithelial ovarian cancer.

Any use of short tandem repeat (STR) markers for the treatment of epithelial ovarian cancer is considered experimental, investigational and unproven.

Rationale

High-dose chemotherapy (HDC) followed by hematopoietic stem-cell (HSC) transplant (HSCT) or stem-cell support (SCS) (i.e., blood or marrow) transplant is an effective treatment modality for many patients with certain malignancies and non-malignancies. The rationale of this treatment approach is to provide a very dose-intensive treatment in order to eradicate malignant cells followed by rescue with peripheral blood, umbilical cord blood, or bone marrow stem-cells. 

Initially, this policy was based on a 1998 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment (5) that reached the following conclusions:

  • Data was unavailable from randomized controlled trials for any of the patient groups studied. Thus, the Assessment was able to compare outcomes only indirectly, using separate studies of HDC and conventional dose regimens. Although some results reported after high-dose therapy appeared encouraging, the indirect comparisons did not permit conclusions.
  • In previously untreated patients, reported response rates suggested that high-dose therapy increased the objective response rate compared to patients given conventional-dose chemotherapy. However, this comparison was flawed by age bias and by differences in performance status and other baseline characteristics of patients included in the two sets of studies. Response duration and survival data were unavailable for comparison. Treatment-related mortality was greater after high-dose therapy.
  • In previously treated patients, objective response rates after HDC also were reportedly higher than after conventional-dose regimens. Subgroup analyses showed higher response rates among platinum-sensitive, optimally debulked patients. Minimum values of the ranges reported across studies for median response duration and survival after HDC were similar to those reported after conventional-dose chemotherapy. However, the maxima for these ranges suggested improved response duration and overall survival after high-dose therapy. In contrast, data from the Autologous Blood and Marrow Transplant Registry did not show similarly high survival for comparable subgroups. Comparison with conventional-dose chemotherapy was again biased due to differences in age distributions, performance status, and other baseline characteristics of patients included in studies of high-dose or conventional therapies.

The 1998 TEC Assessment did not identify any studies reporting outcomes of allogeneic transplants for patients with ovarian cancer. A separate 1999 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment (6) evaluated the use of HDC with allogeneic stem-cell support (HDC/AlloSCS) as a salvage therapy after a failed prior course of HDC with autologous stem-cell support (HDC/AuSCS). There was no data regarding outcomes of this strategy as therapy for epithelial ovarian cancer.

Several uncontrolled studies were published after the 1998 TEC Assessment. These reported retrospective or prospective analyses on outcomes of high-dose regimens followed by AuSCS for ovarian cancer patients who were previously untreated (7, 8, 9) had residual disease or a responding relapse, (10, 11, 12) or for mixed groups of these patients. (13, 14, 15, 16) Registries in North America (17) and Europe (18, 19) also reported retrospective analyses that may include some of the same patients. Taken together, these data were judged inadequate to alter conclusions of the 1998 TEC Assessment. Recent reviews (20, 21) and an editorial (22) did not cite convincing evidence that benefits from high-dose therapy is superior to those of conventional-dose management for any group of patients with ovarian cancer.

The abstract by Cure and coworkers, (23) from the June 2004 meeting of the American Society for Clinical Oncology, reported on a Phase III randomized trial outcomes of women with advanced ovarian cancer randomly assigned after second-look surgery to receive either HDC with peripheral blood stem-cell support or conventional-dose maintenance chemotherapy, which included (10) either HDC with carboplatin-cyclophosphamide or three cycles of a conventional-dose maintenance regimen. These results were presented in abstract form and have yet to be published. Patients were younger than age 60 years with FIGO stage III-IV and disease sensitive to first-line chemotherapy. Enrolled were 110 patients (n=57 high-dose and n=53 conventional-dose chemotherapy). Median follow-up was 60 months. No difference was seen in disease-free or OS between the two arms. Disease-free survival in the conventional- versus the high-dose group was 12.2 months (95% CI: 7.3–17.1) versus 17.5 months (95% CI: 5.2–29.9) (p=0.22), respectively. OS was 42.5 months (95% CI: 28.8-56.6) and 49.7 months (95% CI: 29.9–69.4), respectively (p=0.43). The authors reported no significant differences in disease free-survival or overall survival in either treatment group. (23) These findings suggest HDC/AuSCS cannot be supported as a treatment of advanced ovarian cancer over conventional-dose maintenance.

Clinical Guidelines

National Comprehensive Cancer Network (NCCN) Guidelines:

In addition, the National Comprehensive Cancer Network clinical practice guidelines for ovarian cancer indicate that HDC/AuSCS is considered investigational for the treatment of ovarian cancer. (2)

National Cancer Institute (NCI) Clinical Trials Database (PDQ®)

The National Cancer Institute (NCI) database of clinical trials (PDQ®) was searched for ongoing trials investigating high-dose therapy for patients with ovarian cancer. The PDQ® search identified only one open trial specifically focused on patients with ovarian cancer investigating HDC followed by hematopoietic stem-cell transplant:

  • A Phase II trial using cyclophosphamide, carboplatin, and mitoxantrone followed by autologous bone marrow transplant for patients with refractory or relapsed ovarian cancer (NCI-V91-0058).

Additional Infusion Treatments for Epithelial Ovarian Cancer

Tandem or triple stem-cell transplant and donor leukocyte infusion (DLI)  for ovarian cancer is considered experimental, investigational and unproven due to lack of adequate evidence of safety and effectiveness documented in published, peer-reviewed medical literature.

2013 Update

A search of peer reviewed literature through October 2012 was conducted. The following is a summary of the key literature to date.

Experience with SCS in epithelial ovarian cancer is primarily derived from registry data and Phase II trials. (17, 18, 24) Over the last 20 years, more than 1,000 patients have been entered on transplant registries in Europe and in the United States. (4, 17, 18) Many of the registry patients were treated following relapse and others in nonrandomized studies using HDC as first-line treatment. Case selection and retrospective review make the interpretation of the registries and nonrandomized data difficult. (4) Survival analyses from registry data and clinical trials suggested a possible benefit treating ovarian cancer patients with SCS.

However, as outlined here, none of the randomized trials that have been performed have provided evidence that HSCT in ovarian cancer provides any outcome benefit.

In 2007, Mobus and colleagues reported on a trial of 149 patients with untreated ovarian cancer who were randomly assigned, after debulking surgery, to standard chemotherapy or sequential HDC and peripheral blood stem-cell support. (4) This was the first randomized trial comparing HDC to standard chemotherapy as first-line treatment of ovarian cancer, and the investigators found no statistically significant difference in progression-free survival (PFS) or OS between the two treatment options. The median patient age was 50 years (range: 20–65) and International Federation of Gynecology and Obstetrics (FIGO) stage was IIb/IIc in 4%, III in 78%, and IV in 17%. Seventy-six percent of patients in the HDC arm received all of the scheduled chemotherapy cycles. After a median follow-up of 38 months, PFS was 20.5 months in the standard chemotherapy arm and 29.6 months in the HDC arm (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.56–1.26; p=0.40). Median OS was 62.8 months in the standard chemotherapy arm and 54.4 months in the HDC arm (HR: 1.17; 95% CI: 0.71–1.94; p=0.54).

In 2008, Papadimitriou and colleagues reported on the use of HDC with SCS as consolidation therapy in patients with advanced epithelial ovarian cancer (FIGO stage IIC-IV). (3) Patients who achieved first clinical complete remission after conventional chemotherapy were randomly assigned to receive or not receive high-dose melphalan and AuSCS. A total of 80 patients were enrolled in the trial. Of the 37 patients allocated to HDC, 11 did not receive the treatment either due to refusal or failure of peripheral blood stem-cell mobilization. In an intent-to-treat analysis, there were no significant differences between the two arms in time-to-disease progression (p=0.059) or OS (p=0.38).

Additional Infusion Treatments for Epithelial Ovarian Cancer Using Hematopoietic Progenitor Cell (HPC) Boost or Stem-Cell Boost (SCB)

As with DLI, HPC Boost has a positive response rate for relapse following AlloSCS to treat hematological malignancies. (25) The boost of stem-cells, a second dose, may be helpful to reduce the graft failure process, avoiding the risk of serious bleeding and/or infection. However, the data is insufficient for the use of HPC Boost following AlloSCS for treatment of non-hematological malignancies to lessen post-transplant graft failures. (25, 26, 27, 28)

Short Tandem Repeat (STR) Markers

Following SCS therapy, it is important to determine whether the new blood forming system is of the donor or the recipient, based upon the proportion of donor and recipient cells. The characteristics of the engraftment are analyzed, which is called chimerism analysis. Using STR marker assay to characterize the hematological course and to evaluate the usefulness of the blood forming system (particularly for hematological malignancies, myelodysplastic/myeloproliferative processes, or certain genetic or metabolic disorders) has been tested initially after the SCS, when the patient is declared as disease-free, and at the point of the confirmed stable engraftment of only the donor pattern of the blood forming system. (29, 30) Without further randomized trials using STR markers prior to or post SCS therapy for treatment of epithelial ovarian cancer, the data is insufficient to determine the outcome/effect of stem-cell engraftment. (29, 30, 31, 32, 33, 34)

Clinical Guidelines

National Comprehensive Cancer Network (NCCN) Guidelines:

Current NCCN Guidelines for ovarian cancer did not indicate any type of HDC with SCS for the treatment of ovarian cancer at any stage or within any progression/recurrence of the disease. (2)

National Cancer Institute (NCI) Clinical Trials Database (PDQ®):

As of October 2012, no Phase III trials investigating HDC therapy for patients with ovarian epithelial cancer were identified in the 2012 National Cancer Institute database.

Summary

The evidence for the use of SCS as an adjunct to HDC epithelial ovarian cancer is based on 2 published randomized trials with conflicting outcomes, and data from case series and registries. At present, the evidence is insufficient to recommend this intervention in either first-line therapy or for patients in whom epithelial ovarian cancer has relapsed following standard chemotherapy, and therefore, the use of SCS in epithelial ovarian cancer remains experimental, investigational and unproven.

Based on a search of peer reviewed literature in the MedLine database, through October 2012, there were no new clinical trial publications or any additional information that would change our coverage position; therefore, tandem or triple stem-cell transplant and DLI remain experimental, investigational and unproven for the treatment of epithelial ovarian cancer.

Based on a search of scientific literature in the MedLine database through March 2013, HPC boost to reduce the graft failure process and STR markers to monitor engraftment chimerism for the treatment of epithelial ovarian cancer are considered experimental, investigational, and unproven due to the lack of adequate evidence of safety and effectiveness documented in published, peer-reviewed medical literature.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

Rationale for Benefit Administration
 
ICD-9 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, 183.0

ICD-10 Codes

C56.1, C56.2, C56.9, 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

Procedural Codes: 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
References
  1. Physician Data Query (PDQ). Ovarian epithelial cancer treatment (PDQ®). National Cancer Institute, U.S. National Institute of Health. Available at http://www.cancer.gov (accessed on 26 October 2012).
  2. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Ovarian Cancer (Including Fallopian Tube Cancer and Primary Peritoneal Cancer). Version 1.2013. http://www.nccn.org (accessed on 2012 October 26).
  3. Papadimitriou C, Dafni U, Anagnostopoulos A et al. High-dose melphalan and autologous stem cell transplantation as consolidation treatment in patients with chemosensitive ovarian cancer: results of a single-institution randomized trial. Bone Marrow Transplant 2008; 41(6):547-54.
  4. Mobus V, Wandt H, Frickhofen N et al. Phase III trial of high-dose sequential chemotherapy with peripheral blood stem cell support compared with standard dose chemotherapy for first-line treatment of advanced ovarian cancer: Intergroup trial of the AGO-Ovar/AIO and EBMT. J Clin Oncol 2007; 25(27):4187-93.
  5. High-Dose Chemotherapy with Autologous Stem-Cell Support for Epithelial Ovarian Cancer. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1998 May) 13(6):1-21.
  6. Salvage HDC/AlloSCS for Relapse following HDC/AuSCS for Non-Lymphoid Solid Tumors. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1999 July) 14(11):1-9.
  7. Wandt, H., Birkmann, J., et al. Sequential cycles of high-dose chemotherapy with dose escalation of carboplatin with or without paclitaxel supported by G-CSF mobilized peripheral blood progenitor cells: a phase I/II study in advanced ovarian cancer. Bone Marrow Transplant (1999); 23(8):763-70.
  8. Bertucci, F., Viens, P., et al. High-dose melphalan-based chemotherapy and autologous stem cell transplantation after second look laparotomy in patients with chemosensitive advanced ovarian carcinoma: long-term results. Bone Marrow Transplant (2000); 26(1):61-7.
  9. Prince, H.M., Rischin, D., et al. Repetitive high-dose topotecan, carboplatin, and paclitaxel with peripheral blood progenitor cell support in previously untreated ovarian cancer: results of a Phase I study. Gynecological Oncology (2001); 81(2):216-24.
  10. Donato, M.L., Gershenson, D.M., et al. High-dose topotecan, melphalan, and cyclophosphamide (TMC) with stem cell support: a new regimen for the treatment of advanced ovarian cancer. Gynecolological Oncology (2001); 82(3):420-6.
  11. Morgan, R.J., Doroshow, J.H., et al. Phase II trial of high-dose intravenous doxorubicin, etoposide, and cyclophosphamide with autologous stem cell support in patients with residual or responding recurrent ovarian cancer. Bone Marrow Transplant (2001); 28(9):859-63
  12. Stiff, P.J., Shpall, E.J., et al. Randomized Phase II trial of two high-dose chemotherapy regimens with stem cell transplantation for the treatment of advanced ovarian cancer in first remission or chemosensitive relapse: a Southwest Oncology Group study. Gynecological Oncology (2004); 94(1):98-106.
  13. Bertucci, F., Viens, P., et al. High-dose chemotherapy with hematopoietic stem cell support in patients with advanced epithelial ovarian cancer: analysis of 67 patients treated in a single institution. Anticancer Research (1999); 19(2B):1455-61.
  14. Shinozuka, T., Miyamoto, T., et al. High dose chemotherapy with autologous stem cell support in the treatment of patients with ovarian carcinoma: long term results for 105 patients. Cancer (1999); 85(7):1555-64
  15. Cook, S., Penson, R., et al. Efficacy and hematologic toxicity of salvage chemotherapy following stem cell-supported high-dose chemotherapy in women with recurrent ovarian cancer. Gynecologic Oncology (2000); 77(1):48-54.
  16. Donato, M.L., Aleman, A., RE et al. Analysis of 96 patients with advanced ovarian carcinoma treated with high-dose chemotherapy and autologous stem cell transplantation. Bone Marrow Transplant (2004); 33(12):1219-24.
  17. Stiff PJ, Veum-Stone J, Lazarus HM et al. High-dose chemotherapy and autologous stem-cell transplantation for ovarian cancer: an autologous blood and marrow transplant registry report. Ann Intern Med 2000; 133(7):504-15.
  18. Ledermann JA, Herd R, Maraninchi D et al. High-dose chemotherapy for ovarian carcinoma: long-term results from the Solid Tumour Registry of the European Group for Blood and Marrow Transplantation (EBMT). Ann Oncol 2001; 12(5):693-9.
  19. Rosti G, Ferrante P, Ledermann J et al. High-dose chemotherapy for solid tumors: results of the EBMT. Current Oncology Reports (2002); 41(2):129-40.
  20. Pujade-Lauraine, E., Cure, H., et al. High dose chemotherapy in ovarian cancer. International Journal of Gynecological Cancer (2001); 11(suppl 1):64-7.
  21. Peethambaram, P.P., Long, H.J. Second-line and subsequent therapy for ovarian carcinoma. Current Oncology Reports (2002); 4(2):159-64.
  22. Sarosy, G.A., Reed, E. Autologous stem-cell transplantation in ovarian cancer: Is more better? Annals of Internal Medicine (2000); 133(7):555-6.
  23. Cure, H., Battista, C., et al. Phase III randomized trial of high-dose chemotherapy (HDC) and peripheral blood stem cell (PBSC) support as consolidation in patients (pts) with advanced ovarian cancer (AOC): 5-year follow-up of a GINECO/FNCLCC/SFGM-TC study. Abstract No: 5006. American Society for Clinical Oncology. 40th annual meeting. New Orleans, Louisiana (2004 June 5-8).
  24. Stiff PJ, Bayer R, Kerger C et al. High-dose chemotherapy with autologous transplantation for persistent/relapsed ovarian cancer: a multivariate analysis of survival for 100 consecutively treated patients. J Clin Oncol 1997; 15(4):1309-17.
  25. ACS – Stem Cell Transplant (Peripheral Blood, Bone Marrow, and Cord Blood Transplants) (2013). American Cancer Society. Available at http://www.cancer.org (accessed – 2013 April 15).
  26. Slatter, M.A., Bhattacharya, A., et al. Outcome of boost hematopoietic stem cell transplant for decreased donor chimerism or graft dysfunction in primary immunodeficiency. Bone Marrow Transplantation (2005) 35:683-9.
  27. Larocca, A., Piaggio, G., et al. A boost of CD35+-selected peripheral blood cells without further conditioning in patients with poor graft function following allogeneic stem cell transplantation. The Hematology Journal (2006) 91(7):935-40.
  28. NIH – Marrsson, J., Ringden, O., et al. Graft failure after allogeneic hematopoietic cell transplantation. Biology and Blood Marrow Transplant (2008 January) 14(Supplement 1):165-70. National Institutes of Health Public Access. Available at http://www.nih.gov (accessed – 2013 April 15).
  29. Borrill, V., Schlaphoff, T., et al. The use of short tandem repeat polymorphisms for monitoring chimerism follow bone marrow transplantation: a short report. Hematology (2008 August) 13(4):210-4.
  30. Crow, J., Youens, K., et al. Donor cell leukemia in umbilical cord blood transplant patients: a case study and literature review highlighting the importance of molecular engraftment analysis. Journal of Molecular Diagnostics (2010 July) 12(4):530-7.
  31. Park, M., Koh, K.N., et al. Clinical implications of chimerism after allogeneic hematopoietic stem-cell transplantation in children with non-malignant diseases. Korean Journal of Hematology (2011 December) 46(4):258-64.
  32. Odriozola, A., Riancho, J.A., et al. Evaluation of the sensitivity of two recently developed STR multiplexes for the analysis of chimerism after hematopoietic stem-cell transplantation. International Journal of Immunogenetics (2013 April) 40(2):88-92.
  33. Lawler, M., Crampe, M., et al. The EuroChimerism concept for standardized approach to chimerism analysis after allogeneic stem-cell transplantation. Leukemia (2012 August) 26(8):1821-8.
  34. Tilanus, M.G. Short tandem repeat markers in diagnostics: what’s in a repeat? Leukemia (2006 August) 20(8):1353-55. Available at http:www.nature.com (accessed – 2013 April 22).
  35. Hematopoietic Stem-Cell Support for Epithelial Ovarian Cancer. Chicago Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 November) Therapy 8.01.23.
  36. Donor Leukocyte Infusion for Hematologic Malignancies Treated with Allogeneic Stem Cell Transplant. Chicago Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2012 May) Medicine 2.03.03.
History
March 2012  New Policy for BCBSMT
October 2013 Policy formatting and language revised.  Policy statement unchanged.  Title changed from "Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer" to "Stem-Cell Transplant for Epithelial Ovarian Cancer".
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Stem-Cell Transplant for Epithelial Ovarian Cancer