TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors

This policy addresses hematopoietic stem cell transplantation (HSCT) for primary germ cell tumors, including testicular cancer. Medically necessary coverage includes a single autologous HSCT after standard chemotherapy when there is a partial response, refractory disease, or relapse, and a planned tandem autologous HSCT only for primary testicular cancer meeting the same post-chemotherapy criteria. Not covered: single autologous HSCT as initial therapy in lieu of standard chemotherapy for poor-prognosis disease, tandem HSCT for non-testicular germ cell tumors, any allogeneic HSCT, second/repeat autologous HSCT for persistent/progressive/relapsed disease, or stem cell harvesting for an unscheduled future transplant.

"Asingle autologous hematopoietic stem cell transplantationis consideredmedically necessaryas a treatment of primary germ cell tumors*in individuals treated with standard chemotherapy who hadoneof t..."