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Medical Policy Revision: Hematopoietic Cell Transplantation for Hodgkin Lymphoma

Starting August 18, 2021, Horizon BCBSNJ and Horizon NJ Health will change how we consider Prior Authorization/Medical Necessity Determination (PA/MND) requests and claims submitted for services related to tandem autologous transplant for the treatment of Hodgkin lymphoma. These services will be considered investigational and claims submitted for these services will no longer be eligible for reimbursement. Autologous Hematopoietic Cell Transplantation (HCT) and allogeneic HCT remain eligible for coverage in appropriate clinical circumstances; this change applies to tandem HCT only.

This policy update is being made based on revisions to our HCT for Hodgkin Lymphoma medical guidelines. There is insufficient evidence in current published medical literature to support that tandem autologous transplant results in improved net health outcomes in patients with Hodgkin lymphoma.

We strongly encourage you to review the guidelines of our Hematopoietic Cell Transplantation for Hodgkin Lymphoma online.

This policy update will impact your patients enrolled in fully insured commercial plans, Medicaid plans and patients covered by Administrative Services Only (ASO) employer groups, including the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP).

Unless Horizon BCBSNJ gives written notice that all or part of this update has been cancelled or postponed, the changes will be applied to authorizations and claims for tandem autologous transplant services for the treatment of Hodgkin lymphoma beginning on August 18, 2021.

National Coverage Determination for Medicare Advantage members

We follow the Centers for Medicare & Medicaid Services’ (CMS) National Coverage Determination (NCD) for Stem Cell Transplantation in our review and processing of claims for services provided to our Medicare Advantage members. View CMS' NCD guidelines here.

We will apply our policy guidelines for tandem autologous HCT and second autologous HCT for relapsed lymphoma after a prior autologous HCT for patients enrolled in Horizon BCBSNJ Medicare Advantage plans.

Published on: May 17, 2021, 15:39 p.m. ET
Last updated on: May 11, 2021, 15:47 p.m. ET