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Hematopoietic Cell Transplantation for ChronicMyelogenous Leukemia
Policy His tory
A dditiona l In form at ion
Number: 0674 *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Aetna considers allogeneic hematopoietic cell
transplantation medically necessary for the treatment of
chronic myelogenous leukemia (CML) when the member
meets the transplanting institution's written eligibility criteria. In
the absence of such criteria, Aetna considers allogeneic
hematopoietic cell transplantation medically necessary for the
treatment of members with CML who have failed to respond to,
who have developed resistance to, or who are intolerant to
tyrosine kinase inhibitors (imatinib, dasatinib, nilotinib) for
persons without serious organ dysfunction based on the
transplanting institution's evaluation.
Aetna considers autologous hematopoietic cell transplantation
(auto BM/PSCT) experimental and investigational for the
treatment of CML under all circumstances because its
effectiveness for this indication has not been established.
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 2 of 21
See also CPB 0404 - Interferons
(../400_499/0404.html) CPB 0634 - Non-myeloablative
Hematopoietic Cell Transplantation (Mini-Allograft /
, Conditioning Transplant) (0634.html)
, CPB 0638 - Donor Lymphocyte Infusion (0638.html),
CPB 0640 - Hematopoietic Cell Transplantation for Selected
and Leukemias (0640.html)
Chronic Myelogenous Leukemia:
Chronic myelogenous leukemia (CML) is a hematologic
malignancy associated with a specific chromosomal
abnormality in the form of the Philadelphia chromosome (Ph).
This Ph abnormality represents a reciprocal balanced
translocation between the long arms of chromosomes 9 and
22, and produces the BCR–ABL fusion gene, which leads to
the expression of an abnormal protein. The resulting chimeric
protein is known as p210BCR–ABL, which is characterized by
constitutive activation of its tyrosine kinase activity. At
diagnosis, the Ph can be detected in about 95 % of patients
with CML. The incidence of CML is 1 to 2 cases per 100,000
per year. Chronic myelogenous leukemia accounts for
approximately 15 % of all leukemias and 7 % to 20 % of all
adult leukemias. Although CML can occur at any age, it most
often appears in adults with a median age of 45.
A hallmark of CML is the over-production of granulocytes.
Clinically, CML is characterized by an initial chronic or stable
phase lasting a median of 3 years. During this phase there is
a disordered maturation and excessive proliferation of myeloid
cells. Clinical manifestations that appear during the chronic
phase can usually be controlled with cytotoxic drugs or splenic
irradiation, however true remissions are rare and for the most
part the marrow remains predominantly populated with
leukemic cells. The chronic phase typically transforms into an
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 3 of 21
acute phase, known as a blast phase or crisis, which is usually
terminal. In many patients the blast phase is preceded by an
accelerated phase characterized by progression of symptoms
and resistance to treatment. Conventional chemotherapy
(e.g., busulfan, and other alkylating agents such as
cyclophosphamide and anti-metabolites) used for chronic
phase CML can induce multiple remissions and delay the
onset of blast phase to a median of 4 to 6 years.
Until recently, treatment options for patients with CML, in
addition to conventional chemotherapy, include interferon-
based therapies or allogeneic bone marrow/peripheral stem
cell transplantation (allo BM/PSCT). Treatment decisions are
generally based on the age of the patient and the phase of the
disease. Recently, several new therapies have been
developed that may change the natural history of CML and
patient prognosis. One of the new therapies is imatinib
mesylate (ST1571, Gleevec), an oral, selective BCR-ABL
kinase inhibitor that has demonstrated activity in all phases of
CML. It has been reported that imatinib produces both
hematologic and cytogenetic remission in CML patients. In
CML patients in the chronic phase, who had previously failed
interferon, imatinib induced a complete hematologic response
in 88 % and a complete cytogenetic response in 30 % of
patients. This agent has been rapidly adopted into treatment
strategies for CML. However, the response rate generally
decreases in patients with accelerated or blast phase CML.
Conventional chemotherapy during the chronic phase may
improve the patient’s quality of life, however, it does not (i)
influence the duration of the chronic phase, (ii) prevent
blastic crisis, or (iii) prolong the overall survival time.
Currently, allo BM/PSCT is considered the only potentially
curative therapy for CML. Due to the indolent nature of the
disease and the morbidity and mortality associated with BMTs,
allo BMT was initially limited to patients with CML already in
blast crisis. Although treatment with high-dose chemotherapy
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 4 of 21
(HDC), followed by allo BMT (during blast phase) induced
transient disappearance of the Ph, relapses were common and
survivals short. The somewhat disappointing results were
attributed to the advanced stage of disease and the debilitated
nature of the recipients. Subsequent attempts to perform
transplantation during the accelerated phase did result in
prolonged disease-free survival (DFS) in a small proportion of
patients. However, the incidence of relapse was high. Thus,
focus was shifted to initiating HDC and allo BMT during the
chronic phase of the disease. Results for this therapy during
the chronic phase were very encouraging. As a result,
patients are offered the option of treatment with an allo BMT
as soon as possible following initial diagnosis of chronic phase
CML, prior to evidence of disease progression.
Hehlmann and colleagues (2007) noted that early allo-PSCT
has been proposed as primary treatment modality for patients
with CML. This concept has been challenged by
transplantation mortality and improved drug therapy. In a
randomized study, primary allo-PSCT and best available drug
treatment (interferon-based) were compared in newly
diagnosed chronic phase CML patients. Assignment to
treatment strategy was by genetic randomization according to
availability of a matched related donor. Evaluation followed
the intention-to-treat principle. A total of 621 patients with
chronic phase CML were stratified for eligibility for allo-PSCT.
Three hundred and fifty four patients (62 % male; median age
of 40 years; range of 11 to 59 years) were eligible and
randomized. A total of 135 patients (38 %) had a matched-
related donor, of whom 123 (91 %) received a transplant within
a median of 10 months (range of 2 to106 months) from
diagnosis; 219 patients (62 %) had no related donor and
received best available drug treatment. With an observation
time up to 11.2 years (median of 8.9 years), survival was
superior for patients with drug treatment (p = 0.049),
superiority being most pronounced in low-risk patients (p =
0.032). The authors stated that the general recommendation
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 5 of 21
of allo-PSCT as first-line treatment option in chronic phase
CML can no longer be maintained. It should be replaced by a
trial with modern drug treatment first.
High-dose chemotherapy followed by allo BM/PSCT is
currently considered the only potentially curative therapy for
CML. Studies have confirmed that patients who receive allo
BM/PSCT during the chronic phase have significantly better
survival rates than those who receive transplants during the
accelerated or blast phase.
Fyles et al (1991) reported on long-term results of allo BMT for
patients with CML (n = 70). Patients were stratified according
to risk (good risk subgroup was defined as first chronic phase
CML; poor risk subgroup was defined as other than first
chronic phase CML), as well as diagnosis. The median follow-
up was 67 months with a range of 33 to 120 months.
According to the authors, the most important factor that
determined the outcome in this patient population was disease
status at the time of BMT. The effect of risk status was
evaluated separately for each diagnosis. Good risk patients
with CML had a 5-year event-free survival (EFS) of 43 %, as
compared to the poor risk patients who had only a 15 %
chance of DFS over the same time interval. Patients with CML
in first chronic phase showed a significantly better long-term
EFS than patients transplanted with more advanced disease.
The effect of risk status was also evaluated for each diagnostic
subgroup. Patients with CML in the good risk category
relapsed significantly less frequently at 5 years than poor risk
patients: 13 % versus 58 %. Sixteen patients with CML
relapsed. A hematologic relapse was noted in 14 of these 16
recipients. All 14 were in the poor risk category and eleven of
the 14 poor risk recipients have died from their disease. The
remaining 2 patients (categorized as good risk) relapsed
cytogenetically only. Both of these patients were treated with
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 6 of 21
interferon and have subsequently become Ph negative. The
authors concluded that in order to achieve the best results,
patients should be transplanted early in their disease.
Wagner et al (1992) described results of a retrospective study
evaluating the efficacy of HDC and total body irradiation
followed by allo BMT in patients with chronic phase CML (n =
75). Patients were classified into groups according to age and
graft-versus-host disease (GVHD) prophylaxis. Groups were
defined as follows: Group 1 -- patients less than 30 years of
age receiving immunosuppressive therapy and unmanipulated
bone marrow; Group 2 -- patients 30 years of age or over
receiving immunosuppressive therapy and unmanipulated
bone marrow; Group 3 -- patients 30 years of age or over
receiving lymphocyte-depleted bone marrow plus
immunosuppressive therapy. Survival rate at 4.5 years was 52
%. When classified by age and GVHD prophylaxis, the
actuarial survival was 65 % in Group 1, 33 % in Group 2, and
38 % in Group 3. In uni-variate analysis, patients age 30
years and over, and the use of lymphocyte-depleted bone
marrow negatively influenced EFS. Thirty-seven of the 79
patients died following BMT. The principal causes of treatment
failure were acute and chronic GVHD and disease relapse.
According to the authors, results of the study confirm previous
reports that allo BMT for CML in chronic phase improves
survival in over 50 % of the patients. In addition, the authors
recommended that for patients aged 55 or younger with CML
in the chronic phase, allo BMT should be considered early
after disease presentation.
Gratwohl and co-workers (1993) conducted a retrospective
analysis on data collected by the European Bone Marrow
Transplantation Group since 1979. A total of 1,480 BMTs for
CML were done between 1979 and 1990. Of these, 1,082
patients were transplanted in first chronic phase, 88 in a
subsequent chronic phase, 251 in accelerated phase and 59 in
blast crisis. For these 4 disease stages leukemia-free survival
at 5 years was 39 %, 22 %, 22 % and 0 %, respectively. A
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 7 of 21
more detailed analysis was done on 947 patients who received
transplants in the first chronic phase from an human leukocyte
antigen (HLA)-identical sibling. There were 526 patients alive
2 to 10 years after transplant, 409 have died and 12 were lost
to follow-up. The great majority who died, 350 patients, had a
transplant-related death, while 59 patients died with or due to
relapsed disease. Of the 526 patients alive, 428 were alive
without any signs of relapse, 98 were alive with relapse. This
meant a total of 157 patients relapsed. The probability of
staying alive without relapse at 8 years was 34 %. Since not
all patients with relapse have died, actual survival is better and
the probability of being alive for the whole group was 47 % at 8
years. This long-term analysis allowed a few conclusions: (i)
patients with CML in blastic transformation should not be
considered routine candidates for BMT; (ii) BMT should be
carried out as soon after diagnosis as possible if an HLA-
identical sibling is available; and (iii) age, donor/recipient
sex combination, time span from diagnosis to transplant
and initial disease status influence outcome.
The National Comprehensive Cancer Network’s practice
guidelines on CML (2003) states that 3 effective modalities are
currently available for the primary management of CML: (i)
allo-BMT, (ii) interferon alpha with or without cytarabine,
and (iii) imatinib mesylate. Moreover, in a recent review on
therapeutic strategies for the treatment of CML, Garcia-
Manero et al (2003) stated that allo-PSCT is curative in
selected patients, and is most effective when carried out
during the chronic phase of disease. For patients with a high-
predicted risk of disease recurrence (e.g., transplantation in
accelerated-blastic phase) after allo-PSCT, preventive post-
allo-PSCT maintenance measures such as interferon alpha or
imatinib may be beneficial.
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 8 of 21
Guidelines from the British Society of Haematology on
CML (Goldman, 2007) state that allogeneic stem cell
transplantation may be considered for patients with suitable
donors as an alternative to a second generation tyrosine
kinase inhibitor or if they fail such treatment.
Guidelines from Cancer Care Ontario (Imrie et al, 2009) state
that allogeneic stem cell transplantation is an option for
patients with CML for whom medical therapy has failed, as well
as those in accelerated phase or blast crisis.
Chalandon et al (2014) noted that patients with CML relapsing
after allogeneic stem cell transplantation may be treated by
tyrosine kinase inhibitors and/or by donor lymphocyte
infusions. Best strategies and timing of administration of
lymphocytes are unclear. These investigators analyzed 155
patients who relapsed after allogeneic stem cell
transplantation for CML with disease detectable only by
molecular methods and who subsequently received
lymphocytes. Transplants were performed in first chronic
phase (n = 125) or in advanced disease (n = 29) from identical
siblings (n = 84) or unrelated donors (n = 71) between 1986
and 2003. They received lymphocytes either during molecular
relapse (n = 85) or upon progression to more advanced
disease between 1993 and 2004. The median interval from
relapse to lymphocytes infusion was 210 (0 to 1,673) days.
The median follow-up after it was 46 (3 to 135) months.
Overall survival was 76 ± 4 % at 5 years after lymphocyte
infusions (89 ± 8 % with sibling donors and 63 ± 13 % with
unrelated donors (p = 0.003)). Survival was 69 ± 14 % if
lymphocytes were given within 6 months of the detection of
molecular relapse and 81 ± 10 % (p = 0.061) if given later; 81
± 11 % if given at molecular relapse versus 71 ± 12 % (p =
0.26) with more advanced disease. In multi-variate analysis
survival was worse if the donor was unrelated (HR 2.54 (95 %
confidence interval [CI]: 1.15 to 5.53), p = 0.021) and better
with lymphocyte infusion beyond 6 months from molecular
relapse (HR 0.4 (95 % CI: 0.19 to 0.84), p = 0.0.018). These
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia - Medical Clinic... Page 9 of 21
data confirmed the remarkable effectiveness of lymphocyte
infusion for this disease. The authors concluded that there
appears to be no advantage of administering it early upon
detection of molecular relapse in patients who received
allogeneic stem cell transplantation for CML.
Kitanaka (2016) noted that the introduction of tyrosine kinase
inhibitors (TKIs) has dramatically changed the management of
patients with CML. Despite improved outcomes for most CML
patients, disease progression from chronic phase (CP) to
accelerated phase (AP) or blast phase (BP) occurs in 1 to 1.5
% of cases per year with current TKI therapy. In addition,
about 10 to 15 % of newly diagnosed patients present in AP or
BP. Even in the TKI era, the prognosis of patients with CML-
AP is not satisfactory. Although de-novo AP patients who
respond optimally to TKI have excellent outcomes, the
prognosis of the remaining CML –AP patients treated with TKI
remains poor. For CML-AP patients, allogeneic stem cell
transplantation (allo-HSCT) is the only curative therapy.
Patients eligible for allo-HSCT should first be treated with TKI
with or without chemotherapy, in order to obtain reversion to
CP, followed promptly by allo-HSCT. The author concluded
that the survival rates of patients undergoing allo-HSCT for
CML-AP are still disappointing; prophylactic or pre-emptive
use of TKIs after allo-HSCT may improve long-term survival.
They stated that further investigation to improve the treatment
outcomes of patients with CML-AP is needed.
Shulman and associates (2016) stated that the management
of CML in children changed dramatically with the introduction
of TKIs. Unfortunately, outcomes for patients presenting in an
advanced stage (AP- or BP-CML) continues to be poor,
requiring chemotherapy and all-HSCT to attempt cure.
Integration of TKIs in the therapy of advanced CML is still an
area of active investigation. There are little published data on
TKI use in children with advanced stage CML. These
researchers performed a retrospective review of all children
treated at their institution between January 1, 2010 and June
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 10 of 21
30, 2013, and identified 5 children, aged 12 to 18 years, with
advanced stage CML. All patients were treated with a TKI
before allo-HSCT and TKIs were re-started following allo-
HSCT in 4/5 with a goal of continuing until 2 years post-
transplant. At time of allo-HSCT, all were in a morphologic
and cytogenetic remission; 1 patient had also achieved
molecular remission. All patients were alive and in molecular
remission at an average of 38 months (range of 14 to 51
months) following transplant. The authors concluded that their
experience indicated that TKIs were safe and well-tolerated in
children both pre-transplant and post-transplant and may
improve outcomes in this aggressivedisease.
Londo and colleagues (2017) noted that TKIs are widely used
to treat patients with CML-CP, and outcomes of TKI treatment
for patients with CML-CP have been excellent. Since multiple
TKIs are currently available, 2nd-line or 3rd-line TKI therapy is
considered for patients who are intolerant of or resistant to the
previous TKI treatment. Thus, allo-HSCT is considered only
for patients with disease progression or for patients after
treatment failure with multiple TKIs. To reflect the current
clinical situation of patients with CML-CP, these investigators
examined if prior TKI treatment affects the outcome of allo-
HSCT. Data from 237 patients for whom the number of pre-
transplant TKIs varied from 1 to 3 were used for analysis.
Before allo-HSCT, 153 patients were treated with 1 TKI, 49
patients were treated with 2 TKIs, and 35 patients were treated
with 3 TKIs. In addition to conventional risk factors, i.e.,
disease status at transplantation and patient's age, the use of
3 TKIs before transplantation was identified as a significant
adverse factor for prognosis. Non-relapse mortality rate was
higher in patients treated with 3 TKIs than in patients treated
with 1 or 2 TKIs. The authors concluded that these findings
suggested that allo-HSCT could be considered for young
patients with CML-CP who manifest resistance to 2nd-line TKI
therapy and who have an appropriate donor.
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 11 of 21
Available scientific evidence has not established autologous
bone marrow/peripheral stem cell transplantation (auto-
BM/PSCT) as an effective treatment for CML. Patient
populations varied across these studies. Some focused on
newly diagnosed patients or those in the first year since
diagnosis. Others focused on patients who did not respond to
or relapsed after initial treatment using interferon alpha.
Finally, some focused on patients transplanted in late chronic
phase or after transformation to accelerated phase or blast
crisis. Although some patients achieved complete or partial
molecular remissions and long-term DFS, these studies do not
permit conclusions free from the influence of patient selection
bias. Moreover, all autotransplanted patients included in these
reports were treated before Gleevec became available. Since
this drug has been shown to induce major hematologic and,
less often, cytogenetic remissions even among patients in
accelerated phase and blast crisis, future studies of
autotransplants for CML, may focus on patients who fail or
become resistant to imatinib mesylate. Alternatively, it may be
incorporated into combination regimens used for high dose
Bhatia et al (1997) stated that the role of autologous
transplantation in the early therapy of CML is not yet
understood. Analysis of a first generation of autologous
transplants performed largely in previously treated, older
patients unsuitable for allogeneic transplantation or not
responding to interferon alpha therapy suggests that this
approach has anti-leukemia activity associated with
prolongation of survival and acceptable peri-transplantation
mortality. However, because these trials were uncontrolled
and patient selection could have contributed to the longer than
expected survival, controlled studies are needed to confirm the
encouraging findings of these early reports and determine if
autologous transplantation prolongs survival.
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 12 of 21
Podesta et al (2000) examined changes that occur in the
percentage of Ph-negative- and Ph-positive-committed
progenitor cells and ascertained the relationship between
changes and clinical outcome in 15 patients with CML who
were autografted soon after diagnosis with 85 % to 100 % Ph-
negative peripheral blood progenitor cells (PBPC). The
authors reported that a prolonged period of complete or almost
complete Ph-negative hemopoiesis was achieved in patients
with CML who underwent autografting with Ph-negative
progenitors. These researchers stated that longer follow-up
studies are needed to evaluate whether these changes are
associated with improved survival.
Michallet et al (2000) reported data on 28 CML patients
autotransplanted in chronic phase with PBPC mobilized with
G-CSF (5 ug/kg/day for 5 days) given subcutaneously while
continuing interferon alpha therapy. The authors concluded
that the results of this strategy were encouraging in poor
interferon alpha responders, however, other prospective
studies that try to maintain the cytogenetic responses obtained
immediately after transplantation are needed.
Meloni and associates (2001) stated that the potential role of
auto-SCT as an alternative therapeutic strategy in CML has
been widely explored in pilot studies, but the clinical results in
terms of survival have so far been evaluated only
retrospectively and in heterogeneous groups of patients.
These investigators evaluated the feasibility and long-term
efficacy of unmanipulated auto-SCT followed by low dose
interferon alpha in a homogeneous group of patients affected
by CML in a very early phase of disease (n = 26). The authors
concluded that high dose therapy followed by unmanipulated
peripheral blood stem cell transplantation and low-dose
interferon alpha is a feasible approach, which results in long-
term survival in newly diagnosed CML patients. However,
these findings need to be confirmed in controlled trials
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 13 of 21
comparing auto-SCT with other therapeutic approaches, such
as the use of interferon alpha alone or in combination with
Koziner et al (2002) evaluated the role of auto-SCT in
prolonging DFS and overall survival (OS) in patients with CML
who received autografts of Ph-positive or Ph-negative cell
harvests (n = 53). The authors found that auto-SCT with Ph-
negative cell harvests after myeloablative chemotherapy
resulted in prolonged periods of hematologic and cytogenetic
remission or stable disease after cytogenetic/molecular
recurrence in some patients with CML. A superior DFS was
observed without any benefit observed for OS. These
investigators concluded that auto-SCT with Ph-negative cells
is a promising procedure because it can improve the DFS
probability of patients who are unsuitable for allo-SCT from a
The National Comprehensive Cancer Network’s practice
guidelines on CML (2009) as well as a recent review on
therapeutic strategies for the treatment of CML did not discuss
the use of autologous transplantation as a treatment option
(Garcia-Manero et al, 2003). Schiffer and colleagues (2003)
stated that auto-SCT following intense chemoradiotherapy
may prolong survival and reduce complications and mortality
during peri-transplantation in patients with CML, however, this
procedure is not curative. The collection of stem cells when
the patient is in complete cytogenetic response for use in case
of relapse is considered an investigative procedure.
A meta-analysis of 6 randomized studies (CML Autograft Trials
Collaboration, 2007) reported that the results do not suggest a
role for auto-SCT in initial treatment for CML, but it may still
merit investigation in patients resistant to tyrosine kinase
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 14 of 21
Guidelines from Cancer Care Ontario (Imrie, et al., 2009) state
that autologous stem cell transplantation is not recommended
for patients with CML.
The Hematopoietic Cell Transplantion-Specific
Comorbidity Score Calculator is available at the following
Calculate by QxMD (http://www.qxmd.com/calculate
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
CPT codes covered if selection criteria are met:
38230 Bone marrow harvesting for transplantation;
38240 Hematopoietic progenitor cell (HPC); allogeneic
transplantation per donor
38242 Allogeneic lymphocyte infusions
CPT codes not covered for indications listed in the CPB:
38206 Blood-derived hematopoietic progenitor cell
harvesting for transplantation, per collection;
38241 Hematopoietic progenitor cell (HPC);
Other CPT codes related to the CPB:
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 15 of 21
Code Code Description
Bone Marrow or Stem Cell Services/Procedures
HCPCS codes covered if selection criteria are met::
S2150 Bone marrow or blood-derived stem cells
(peripheral or umbilical), allogeneic or
autologous, harvesting, transplantation, and
related complications; including: pheresis and
cell preparation/storage; marrow ablative
therapy; drugs, supplies, hospitalization with
outpatient follow-up; medical/surgical,
diagnostic, emergency, and rehabilitative
services; and the number of days of pre- and
post-trasnplant care in the global definition
Other HCPCS codes related to the CPB:
S0088 Imatinib, 100mg
ICD-10 codes covered if selection criteria are met:
Chronic myeloid leukemia
The above policy is based on the following references:
Allogeneic Bone Marrow Transplantation:
1. Fyles G, Messner HA, Lockwood G, et al. Long-term
results of bone marrow transplantation for patients
with AML, ALL, CML prepared with single dose total
body irradiation of 500cGy delivered with a high dose
rate. Bone Marrow Transplant. 1991;8(6):453-463.
2. Wagner J, Zahurak M, Piantadosi S, et al. Bone marrow
transplantation of chronic myelogenous leukemia in
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia -Medical Cli... Page 16 of 21
chronic phase: Evaluation of risks and benefits. J Clin
Oncol. 1992;10(5) :779-789.
3. Gratwohl A, Hermans J, Niederwieser D, et al. Bone
marrow transplantation for chronic myeloid leukemia:
Long term results. Chronic Leukemia Working Party of
the European Group for Bone Marrow
Transplantation. Bone Marrow Transplant. 1993;12
4. Silver RT, Woolf SH, Hehlmann R, et al. An evidence-
based analysis of the effect of busulfan, hydroxyurea,
interferon and allogeneic bone marrow
transplantation in treating the chronic phase of
chronic myeloid leukemia: Developed for the American
Society of Hematology. Blood. 1999;94(5):1517-1536.
5. Druker BJ, Talpaz M, Resta DJ, et al. Efficacy and safety
of a specific inhibitor of the BCR-ABL tyrosine kinase in
chronic myeloid leukemia. N Eng J Med. 2001;344
6. Goldman JM, Melo JV. Targeting the BCR-ABL tyrosine
kinase in chronic myeloid leukemia. N Engl J Med.
7. Weisdorf DJ, Anasetti C, Antin JH, et al. Allogeneic bone
marrow transplantation for chronic myelogenous
leukemia: Comparative analysis of unrelated versus
matched sibling donor transplantation. Blood. 2002;99
8. O'Dwyer ME, Mauro MJ, Druker BJ. Recent
advancements in the treatment of chronic
myelogenous leukemia. Ann Rev Med. 2002;53:369
9. Garcia-Manero G, Talpaz M, Kantarjian HM. Current
therapy of chronic myelogenous leukemia. Intern Med.
10. Novartis Oncology. Gleevec (imatinib mesylate).
Prescribing Information. East Hanover, NJ: Novartis;
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11. Aetna Inc. Protein kinase inhibitors -- Gleevec.
Pharmacy Clinical Policy Bulletins. Hartford, CT: Aetna;
January 1, 2005.
12. Garcia-Manero G, Faderl S, O'Brien S, et al. Chronic
myelogenous leukemia: A review and update of
therapeutic strategies. Cancer. 2003;98(3):437-457.
13. Dalziel K, Round A, Stein K, et al. Effectiveness and
cost-effectiveness of imatinib for first-line treatment of
chronic myeloid leukaemia in chronic phase: a
systematic review and economic analysis. Health
Technology Assess. 2004;8(28):1-134.
14. Oehler VG, Radich JP, Storer B, et al. Randomized trial
of allogeneic related bone marrow transplantation
versus peripheral blood stem cell transplantation for
chronic myeloid leukemia. Biol Blood Marrow
15. Bornhauser M, Kroger N, Schwerdtfeger R, et al.
Allogeneic haematopoietic cell transplantation for
chronic myelogenous leukaemia in the era of imatinib:
A retrospective multicentre study. Eur J Haematol.
16. Greenberg PL, Baer MR, Bennett JM, et al.
Myelodysplastic syndromes clinical practice guidelines
in oncology. J Natl Compr Canc Netw. 2006;4(1):58-77.
17. Hehlmann R, Berger U, Pfirrmann M, et al. Drug
treatment is superior to allografting as first-line
therapy in chronic myeloid leukemia. Blood. 2007;109
18. Hehlmann R, Hochhaus A, Baccarani M; European
LeukemiaNet. Chronic myeloid leukaemia. Lancet.
19. Goldman J. Recommendations for the management of
BCR-ABL-positive chronic myeloid leukaemia. London,
UK: British Committee for Standards in Haematology;
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20. National Comprehensive Cancer Network (NCCN).
Chronic myelogenous leukemia. NCCN Clinical Practice
Guidelines in Oncology. Jenkintown, PA: NCCN; 2009.
21. Gratwohl A, Heim D. Current role of stem cell
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Amendment to Aetna Clinical Policy Bulletin Number:
0674 Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia
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www.aetnabetterhealth.com/pennsylvania Updated 11/16/2017
Prior Authorization Review Panel MCO Policy SubmissionHematopoietic Cell Transplantation for Chronic Myelogenous LeukemiaCPT Codes / HCPCS Codes / ICD-10 CodesReferencesAmendment to Aetna Clinical Policy Bulletin Number: 0674 Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia