Status

Policy ANTHEM-MP-A045963 addresses hematopoietic stem cell transplantation (HSCT) for multiple myeloma, specifically autologous HSCT (AutoHSCT). AutoHSCT is medically necessary when performed as a single transplant, as tandem transplants 30–180 days apart, as a repeat AutoHSCT performed >180 days after a prior AutoHSCT, or as pretreatment before a non-myeloablative allogeneic HSCT. Investigational/not medically necessary: allogeneic HSCT for multiple myeloma and any HSCT not meeting the above criteria, hematopoietic stem cell harvesting for an unscheduled future transplant when criteria are not met, repeat allogeneic HSCT for persistent/progressive/relapsed disease, and three or more AutoHSCTs within 12 months.

"Autologous hematopoietic stem cell transplantation(AutoHSCT)for treatment of individuals with multiple myeloma is consideredmedically necessarywhen used as:"