CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

This policy addresses donor lymphocyte infusion (DLI) and the collection/cryopreservation of donor lymphocytes for individuals who have undergone allogeneic hematopoietic progenitor cell transplantation for hematologic malignancies. Coverage is medically necessary when DLI is given after a medically necessary myeloablative or nonmyeloablative allogeneic transplant for a hematologic malignancy, using lymphocytes from the same original donor; collection and cryopreservation of donor lymphocytes are also covered before, at the time of, or after the transplant. DLI is not covered for any other indications, and genetic modification of donor lymphocytes as an adjunct to DLI is not covered.

"Donor* lymphocyte infusion is consideredmedically necessaryfor individuals following a medically necessary allogeneic (myeloablative or non-myeloablative) hematopoietic progenitor cell transplant u..."