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Medical Policy

Transplant Section

Policy Name Date Modified
Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant 11/01/2019
Heart Transplant 05/01/2020
Heart-Lung Transplant 05/01/2020
Hematopoietic Cell Transplantation Policies  

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

12/01/2019

Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

04/01/2020

Autologous Hematopoietic Cell Transplantation for Malignant Astrocytomas and Gliomas

04/01/2020

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

05/01/2020

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

04/01/2020

Hematopoietic Cell Transplantation for Autoimmune Diseases

08/01/2019

Hematopoietic Cell Transplantation for Breast Cancer

04/01/2020

Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

12/01/2019

Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia

12/01/2019

Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

12/01/2019

Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

11/01/2019

Hematopoietic Cell Transplantation for Hodgkin Lymphoma

03/01/2020

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

06/01/2019

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

04/01/2020

Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome

03/01/2020

Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphomas

12/01/2019

Hematopoietic Cell Transplantation for Solid Tumors of Childhood

12/01/2019

Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors

11/01/2019
Islet Transplantation 01/01/2020

Isolated Small Bowel Transplant

04/01/2020
Liver Transplant 05/01/2019
Lung and Lobar Lung Transplant 06/01/2019
Pancreas Transplant 12/01/2019
Placental and Umbilical Cord Blood as a Source of Stem Cells 04/01/2020
Small Bowel/Liver and Multivisceral Transplant 05/01/2019