Rule 23-202-4.17 - Peripheral Stem Cell TransplantA. 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.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.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.17. Transplant facilities must meet Medicaid facility criteria.C. Peripheral stem cell transplants are not covered when the candidate has one of the following: 1. Active chemical dependency, drugs or alcohol, within the preceding six (6) months.4. Uncorrectable absence of an essential psychosocial support system.5. Unmanageable psychiatric disorder felt to significantly compromise the candidate's compliance with the post-transplant regimen.23 Miss. Code. R. 202-4.17
Miss. Code Ann. § 43-13-121; 42 CFR §482.90 - 104Revised 04/01/2013, 10/01/2012