TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

This policy addresses hematopoietic stem cell transplantation (HSCT) and stem cell harvesting for pediatric neuroblastoma. Coverage is provided for autologous HSCT as initial therapy for high‑risk neuroblastoma (including planned tandem autologous HSCT), for primary refractory or recurrent neuroblastoma in patients without prior HSCT, for repeat autologous HSCT only in cases of primary graft failure or failure to engraft, and for stem cell harvesting when neuroblastoma criteria are met and a future transplant is likely. Not covered are autologous HSCT when criteria are not met; any allogeneic HSCT (single or tandem) for neuroblastoma; a second/repeat autologous HSCT for persistent, progressive, or relapsed disease; and harvesting when coverage criteria are not met.

"Anautologous hematopoietic stem cell transplantationis consideredmedically necessaryas the initial treatment for high-risk neuroblastoma."