Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.17 - Peripheral Stem Cell Transplant

Current through June 25, 2024
A. No prior
				authorization is required.
B.
				Peripheral Hematopoietic Stem Cell Transplants (PSCT), Autologous, Syngeneic,
				or Allogeneic, are covered for inpatient and outpatient when the following
				criteria are met:
1. Candidate is less than
				fifty-six (56) years of age for allogeneic, < sixty-six (66) if fully
				matched sibling donor.
2. Candidate
				is less than seventy (70) years of age for autologous.
3. Karnofsky >70 or ECOG <3.
4. Allogeneic HLA-MLC match, 1 antigen
				mismatch accepted.
5. Infections
				controlled for forty-eight (48) hours prior to transplant.
6. Left ventricular ejection fraction
				>40%.
7. FEV1 of >50% of
				predicted.
8. Dlco> 60% of
				predicted.
9. All other treatments
				have been attempted or considered and none will prevent progressive disability
				and/or death.
10. The candidate
				and/or legal representative understands the transplant risks and benefits,
				gives informed consent, and has the capacity and is willing to comply with
				needed care, including immunosuppressive therapy.
11. The candidate has been approved by the
				transplant review team.
12. The
				candidate's immunization history and HIV status has been obtained.
13. A psychosocial evaluation has been
				performed for the adult candidate or, if the candidate is a child, for the
				family, with the following results:
a)
				Candidate's psychiatric disorders, if present, are being treated.
b) Candidate's social support system has been
				evaluated and found to be adequate.
c) Candidate has no previous history of
				significant non-compliance to medical treatment.
14. Specific Diagnostic Inclusion Criteria
				(Allogeneic PSCT)
a) Severe aplastic
				anemia.
b) Pure erythrocyte
				aplasia.
c)
				Myelodysplasia.
d) Severe
				hemoglobinopathy, including sickle cell, thalassemia.
e) Selected immunodeficiency syndrome,
				including SCID, Wiskott-Aldrich, Chediak-Higashi.
f) Genetic storage disease, including
				Hurler's, Morquio's.
g) Primary
				amyloidosis.
h) Paroxysmal
				nocturnal hemoglobinuria.
i) Severe
				platelet dysplasia.
j) Acute
				lymphocytic leukemia, in first remission if high risk, at early relapse, or in
				second remission.
k) Acute
				myelogenous leukemia, in same clinical states as listed for acute lymphocytic
				leukemia.
l) Chronic lymphocytic
				leukemia.
m) Chronic myelogenous
				leukemia.
n) Hodgkin's lymphoma,
				failed first line therapy or failed at least one standard chemotherapy
				regimen.
o) Non-Hodgkin's lymphoma,
				failed or responsive to first line therapy or high risk during first
				remission.
p) Familial
				hemophagocytic lymphohistiocytosis (FHL) also known as familial
				erythrophagocytic.
q)
				Lymphohistiocytosis (FEL).
15. Specific Diagnostic Inclusion Criteria
				(Autologous PSCT).
a) Acute lymphocytic
				leukemia, in first remission if high risk, at early relapse, or in second
				remission.
b) Acute myelogenous
				leukemia, in same clinical states as listed for acute lymphocytic
				leukemia.
c) Chronic lymphocytic
				leukemia.
d) Chronic myelogenous
				leukemia.
e) Hodgkin's lymphoma,
				for failed first line therapy or if failed at least one standard chemotherapy
				regimen.
f) Multiple Myeloma single
				autologous BMT/SCT transplant will be considered for beneficiaries with
				Durie-Salmon stage II or stage III disease if this is a newly diagnosed disease
				or responsive multiple myeloma. This includes beneficiaries with previously
				untreated disease, those with at least a partial response to prior chemotherapy
				which is defined as 50% decrease in either measurable serum and/or urine
				paraprotein or in bone marrow infiltration, sustained for at least one (1)
				month, and those in responsive relapse with adequate renal, pulmonary, and
				hepatic function.
g) Recurrent
				solid tumors.
16. Tandem
				BMT/SCT for multiple myeloma is specifically excluded from coverage.
a) Non-Hodgkin's lymphoma, either failed or
				responsive to first line therapy or, if high risk, during first
				remission.
b)
				Neuroblastoma.
c)
				Nephroblastoma.
17.
				Transplant facilities must meet Medicaid facility criteria.