Administration (intra-arterial, intra-thecal, and intravenous) of autologous mesenchymal stem cells for the treatment of multiple system atrophy.The use of mesenchymal stem cell transplantation for the treatment of autoimmune diseases (including ankylosing spondylitis and Sjogren’s syndrome) and selected indications listed in policy statement II.B.Recessive dystrophic epidermolysis bullosaĪetna considers the following interventions experimental and investigational:.Miscellaneous conditions (not an all-inclusive list): Stiff-person syndrome / Stiff-person spectrum disorder.Neuromyelitis optica / neuromyelitis optica spectrum disorder.Chronic inflammatory demyelinating polyradiculopathy. Autoimmune cytopenia (e.g., autoimmune hemolytic anemia, Evans syndrome, and idiopathic thrombocytopenic purpura).Poor lung function (left ventricular ejection fraction (LVEF) of less than 50%).Īetna considers hematopoietic cell transplantation (autologous or allogeneic) experimental and investigational for any of the following because the effectiveness of these approaches for these autoimmune diseases/conditions has not been established:Īutoimmune diseases (not an all-inclusive list):.Severe lung disease (diffusing capacity of the lung for carbon monoxide (DLCO) of less than 40 % of the predicted value or forced vital capacity (FVC) of less than 45 % of the predicted value) or.Poor renal function (creatinine clearance of less than 40 ml/min) or.The member meets the transplanting institutions' selection criteria, or in the absence of such criteria, the member does not have any of the following exclusion criteria:.Previous scleroderma-related renal disease and.Active interstitial lung disease (as determined by broncho-alveolar cell composition or ground-glass opacities on computed tomography of the chest) plus either a forced vital capacity (FVC) or a diffusing capacity of the lung for carbon monoxide (DLCO) of less than 70 % of the predicted value or.This Clinical Policy Bulletin addresses hematopoietic cell transplantation for autoimmune diseases and miscellaneous indications.Īetna considers autologous hematopoietic cell transplantation medically necessary for the treatment of adults (18 to 69 years of age) with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure when either of the following is met: Number: 0606 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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