Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

This policy covers hematopoietic cell transplantation (HCT)—primarily autologous HCT and high‑dose chemotherapy with stem‑cell rescue—as consolidation therapy for pediatric central nervous system (CNS) embryonal tumors (including medulloblastoma) and, in select cases, for recurrent or high‑risk pediatric brain tumors. Coverage is limited to patients with partial or complete response (or stable disease) after induction chemotherapy, requires eligibility based on prior therapy and fitness for intensive conditioning, and tandem autologous and allogeneic HCT (and HCT for ependymoma in many settings) are considered experimental/unproven.

"Autologous HCT may be considered medically necessary as consolidation therapy for previously untreated embryonal tumors of the central nervous system that show partial or complete response to induc..."

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