Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-10A - Transplant Services Standards
Section R414-10A-9 - Hematopoietic Stem Cell Transplantation (HSCT), Covered Services and Requirements
Universal Citation: UT Admin Code R 414-10A-9
Current through Bulletin 2024-06, March 15, 2024
(1) Allogeneic and syngeneic hematopoietic stem cell transplantation may be approved only when the patient has a suitable HLA-matched donor and one of the covered conditions is present.
(a) A search of related family
members, unrelated persons, or both to find a suitable donor is a covered
service.
(2) Patient must have adequate marrow and lack of marrow involvement of primary malignancy if autologous transplant.
(3) Patient must be free from any active infection.
(4) Allogeneic Hematopoietic Stem Cell Transplantation (ASCT) is covered for:
(a)
Leukemia, leukemia in remission, or aplastic anemia; or
(b) Severe Combined Immunodeficiency Disease
(SCID) and for the treatment of Wiskott-Aldrich syndrome.
(5) Autologous Hematopoietic Stem Cell Transplantation (AuSCT) is covered for:
(a)
Acute leukemia in remission with a high probability of relapse and has no Human
Leucocyte Antigens (HLA)-matched;
(b) Resistant non-Hodgkin's lymphomas or
those presenting with poor prognostic features following an initial response;
(c) Recurrent or refractory
neuroblastoma; and
(d) Advanced
Hodgkin's disease with failed conventional therapy and has no HLA-matched
donor.
(e) Single AuSCT is only
covered for Durie-Salmon Stage II or III that fit the following requirements:
(i) Newly diagnosed or responsive multiple
myeloma. This includes those patients with previously untreated disease, those
with at least a partial response to prior chemotherapy (defined as a 50 percent
decrease either in measurable paraprotein (serum, urine or both) or in bone
marrow infiltration, sustained for at least one month), and those in responsive
relapse; and
(ii) adequate
cardiac, renal, pulmonary, and hepatic function.
(f) When recognized clinical risk factors are
employed to select patients for transplantation, High Dose Melphalan (HDM)
together with AuSCT is medically reasonable and necessary for any age group
with primary Amyloid Light (AL) chain amyloidosis who meet the following
criteria:
(i) Amyloid deposition in two or
fewer organs; and
(ii) Cardiac
left ventricular Ejection Fraction (EF) greater than 45 percent.
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