Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

Per NCD 110.23, allo-HSCT is nationally covered for leukemia, aplastic anemia, SCID, and Wiskott-Aldrich syndrome when reasonable and necessary; certain other conditions (MDS, specified multiple myeloma stages, DIPSSplus intermediate-2/high myelofibrosis, and severe symptomatic sickle cell disease) are covered only under Coverage with Evidence Development (CED). This local policy additionally authorizes allo-HSCT for primary refractory or relapsed Hodgkin lymphoma and B- or T-cell non-Hodgkin lymphoma when no other curative-intent options exist, with required documentation of disease status, prior therapies, performance and organ function, infectious screening, psychosocial/financial supports, and consideration/use of risk scores (EBMT or HCT-CI).

"Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is covered for leukemia when reasonable and necessary per NCD 110."