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Medical Policy

Transplant Section

Policy Name Policy ID Number Date Modified

Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant

TRA45.03 12/01/2021
Heart Transplant TRA02 05/01/2022
Heart-Lung Transplant TRA03 05/01/2022
Hematopoietic Cell Transplantation Policies    

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

TRA45.24 12/01/2021

Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

TRA45.25 04/01/2022

Autologous Hematopoietic Cell Transplantation for Malignant Astrocytomas and Gliomas

TRA45.34 04/01/2022

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

TRA45.36 05/01/2022

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

TRA45.28 04/01/2022

Hematopoietic Cell Transplantation for Autoimmune Diseases

TRA45.32 08/01/2022

Hematopoietic Cell Transplantation for Breast Cancer

TRA45.29 03/01/2022

Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

TRA45.33 12/01/2021

Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

TRA45.35 01/01/2022

Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia

TRA45.31 12/01/2021

Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

TRA45.26 11/01/2021

Hematopoietic Cell Transplantation for Hodgkin Lymphoma

TRA45.30 12/01/2021

Hematopoietic Cell Transplantation for Light-Chain (AL) Amyloidosis or Waldenström Macroglobulinemia

TRA45.40 08/01/2022

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

TRA45.27 04/01/2022

Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome

TRA45.22 12/01/2021

Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphomas

TRA45.23 01/01/2022

Hematopoietic Cell Transplantation for Solid Tumors of Childhood

TRA45.37 11/01/2021

Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors

TRA45.38 11/01/2021
Islet Transplantation TRA13 07/01/2021

Isolated Small Bowel Transplant

TRA09 04/01/2022
Liver Transplant TRA05 07/01/2021
Lung and Lobar Lung Transplant TRA08 05/01/2022
Pancreas Transplant TRA06 12/01/2021
Placental and Umbilical Cord Blood as a Source of Stem Cells TRA45.16 04/01/2022
Small Bowel/Liver and Multivisceral Transplant TRA18 05/01/2022
Uterus Transplant TRA19 07/01/2021