TRANS.00038 Thymus Tissue Transplantation

This policy addresses transplantation of allogeneic processed thymus tissue for immune reconstitution in children with congenital athymia. Coverage is medically necessary for a single administration in pediatric patients (generally <18 years) when congenital athymia is confirmed by flow cytometry (<50 naïve T cells/mm3 or <5% naïve T cells), infection-control measures (including immunoprophylaxis) can be maintained until thymic function develops, and there are no comorbidities likely to cause severe complications (e.g., significant renal impairment, CMV or EBV infection). All other uses are investigational and not medically necessary, including use for immune reconstitution in severe combined immunodeficiency (SCID).

"A single administration of allogeneic processed thymus tissue is consideredmedically necessaryfor immune reconstitution in the pediatric population* with congenital athymia whenallof the following ..."