Clinical Policy Title: Stem cell transplants for autoimmune disease

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1 Clinical Policy Title: Stem cell transplants for autoimmune disease Clinical Policy Number: Effective Date: April 1, 2016 Initial Review Date: June 16, 2013 Most Recent Review Date: January 18, 2017 Next Review Date: January 2018 Policy contains: Stem cell transplants. Autoimmune diseases. (AD) Related policies: CP# CP# Bone marrow transplants Stem cell transplant for breast cancer ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health Choice s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice s clinical policies are not guarantees of payment. Coverage policy Prestige Health Choice considers the use of autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation (HSCT) (single or planned tandem) to be investigational, and not medically necessary as a treatment for autoimmune diseases and autoimmunerelated diseases including, but not limited to: Celiac sprue disease. Crohn's disease. Graves disease. Juvenile idiopathic arthritis (JIA). Multiple sclerosis (MS). Neuromyelitis optica. Pernicious anemia. Rheumatoid arthritis (RA). 1

2 Sjögren s syndrome. Systemic lupus erythematosus (SLE). Systemic sclerosis (SSc or scleroderma). Systemic vasculitis. Type 1 diabetes Ulcerative colitis. Note: A complete list of autoimmune diseases is available at the American Autoimmune Related Diseases Association s (AARDA) website, Limitations: Coverage determinations are subject to benefit limitations and exclusions as delineated by the state Medicaid authority. The Florida Medicaid website can be accessed at All other uses of autologous or allogeneic (ablative and non-myeloablative [mini-transplant]) HSCT, single or planned tandem, are not medically necessary. Alternative covered services: Plan approved treatment ordered by treating participating provider. Background Stem cells that form blood and immune cells are known as hematopoietic stem cells (HSCs). They are ultimately responsible for the constant renewal of blood the production of billions of new blood cells each day. Physicians and basic researchers have capitalized on this fact for more than 50 years in treating many diseases. The first evidence and definition of blood-forming stem cells came from studies of people exposed to lethal doses of radiation in A bone marrow transplant, also called a HSCT, is a procedure that replaces damaged or destroyed bone marrow with healthy bone marrow stem cells. Bone marrow is the soft, fatty tissue inside the bones. Stem cells are immature cells in the bone marrow that give rise to all blood cells. There are three basic kinds of stem cell transplants: Autologous bone marrow transplant: The term auto means self. Stem cells are removed from a patient prior to receiving highdose chemotherapy (HDC) or radiation treatment. The stem cells are stored in a freezer (cryopreservation). After HDC or radiation treatments, stems cells are put back in the body 2

3 to regenerate normal blood cells. This is called a rescue transplant. Allogeneic bone marrow transplant: The term allo means other. Stem cells are removed from another person, called a donor. Most times, the donor's genes must at least partly match the member s genes. Special blood tests are done to see if a donor is a good match for the member. A brother or sister is most likely to be a good match. Sometimes parents, children, and other relatives are good matches. Donors who are not related to members may be found through national bone marrow registries. Syngeneic stem cell transplants: This is a special kind of allogenic transplant that can only be used when the recipient has an identical sibling (twin or triplet) who can donate someone who has the same tissue type. An advantage of syngeneic stem cell transplant is that graft-versus-host disease will not be a problem. No cancer cells should be present in a transplant, as there should be no cancer cells in an autologous transplant. Some people may have a HSCT using stem cells from umbilical cord blood. There are cord blood banks that store blood taken from umbilical cords. After the baby is born and the umbilical cord has been cut, a doctor extracts blood from the umbilical cord, and placenta. The blood bank may give the donated stem cells to a person whose blood cells closely match the donated cells. These transplants are mostly used for children, because of the lower volume of cells collected. It may be possible for adults to have a HSCT from two different umbilical cords (double cord transplant). HSCT refers to a procedure in which HSCs are infused to restore bone marrow function in cancer patients who receive bone-marrow, toxic doses of cytotoxic drugs, with or without whole-body radiation therapy. Bone marrow stem cells may be obtained from the transplant recipient (i.e., autologous HSCT) or from a donor (i.e., allogeneic HSCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood and placenta shortly after delivery of neonates. Although cord blood is an allogeneic source, the stem cells in it are antigenically naïve and thus associated with a lower incidence of rejection or graft-versus-host disease (GVHD). Autoimmune Disease The term autoimmune disease (AD) refers to a varied group of illnesses that involve almost every human organ system. It includes diseases of the nervous, gastrointestinal, and endocrine systems, as well as skin and other connective tissues, eyes, blood, and blood vessels. In all of these ADs, the underlying problem is autoimmunity the body s immune system becomes misdirected and attacks the very organs it was designed to protect. Autoimmune diseases are a group of highly heterogeneous disorders with variable organ system involvement, diverse etiologies and pathologies, and different prognoses (Burt, 2008). Standard 3

4 treatment for autoimmune diseases generally consists of immunosuppression, anti-inflammatory and/or anti-malarial medication, and supportive care. Dose escalation of immunosuppressive medication utilizing HSCT is being proposed for individuals who are refractory to standard treatment, or have disease considered to be life-, or organ-threatening. Autoimmune disease affects up to 50 million Americans, according to the American Autoimmune Related Diseases Association (AARDA). An autoimmune disease develops when your immune system, which defends your body against disease, decides your healthy cells are foreign. As a result, your immune system attacks healthy cells. Depending on the type, an autoimmune disease can affect one or many different types of body tissue. It can also cause abnormal organ growth and changes in organ function. There are as many as 80 types of autoimmune diseases. Many of them have similar symptoms, which make them very difficult to diagnose. It s also possible to have more than one at the same time. ADs usually fluctuate between periods of remission (little or no symptoms) and flare-ups (worsening symptoms). Currently, treatment for ADs focuses on relieving symptoms, because there is no curative therapy. AD often runs in families, and 75 percent of those affected are women, according to AARDA. African Americans, Hispanics, and Native Americans also have an increased risk of developing an AD. The cause of AD is unknown. There are many theories about what triggers AD, including: Bacteria or virus. Chemical irritants. Drugs. Environmental irritants. The most common ADs include: Addison s disease Adrenal hormone insufficiency. Celiac sprue disease A reaction to gluten (found in wheat, rye, and barley) that causes damage to the lining of the small intestine. Graves disease Overactive thyroid gland. Hashimoto s disease Inflammation of the thyroid gland. Inflammatory bowel diseases (IDBs) A group of inflammatory diseases of the colon and small intestine. Pernicious anemia Decrease in red blood cells caused by inability to absorb vitamin B-12. Psoriasis A skin condition that causes redness and irritation as well as thick, flaky, silverwhite patches. Rheumatoid arthritis Inflammation of joints and surrounding tissues. Reactive arthritis Inflammation of joints, urethra, and eyes; may cause sores on the skin and mucus membranes. Scleroderma A connective tissue disease that causes changes in skin, blood vessels, 4

5 muscles, and internal organs. Sjögren s syndrome Destroys the glands that produce tears and saliva causing dry eyes and mouth; may affect kidneys and lungs. Systemic lupus erythematosus Affects skin, joints, kidneys, brain, and other organs. Type 1 diabetes Destruction of insulin producing cells in the pancreas. Vitiligo White patches on the skin caused by loss of pigment. Most HSCT procedures for AD treated multiple sclerosis (MS), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), and immune cytopenias (Passweg, 2007). Searches Prestige Health Choice searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on November 14, Search terms were: "autoimmune diseases (MeSH)," stem cells (MeSH)," and multiple sclerosis. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings Currently, there are multiple ongoing clinical trials using autologous and allogeneic HSCT following highdose immunotherapies for the treatment of AD. Burt and colleagues (2006) described lymphoablation or the removal of "autoreactive lymphocytes" through the process of autologous HSCT to promote the generation of new self-tolerant lymphocytes. Examples of ADs being studied in this manner include MS, SSc, RA, Crohn's disease, and lupus. These authors identified the need for further research with randomized controlled trials (RCTs) to verify the benefit and safety of this therapy. 5

6 A major issue for physicians dealing with AD is that although temporary remissions do occur, the conditions are painful and chronic for patients. A growing number of studies suggest that uncontrolled systemic inflammation leads to premature atherosclerosis and cardiovascular deaths, as well as toxicity from chronic immunosuppression, especially glucocorticoids. Despite this, it is still a challenge for a rheumatologist, neurologist, or gastroenterologist to accept an immediate Treatment-Related Mortality (TRM) of 5 to 10 percent, especially because long-term benefits have yet to be demonstrated. The hypothesis is that in a randomized prospective trial of HSCT versus conventional treatment, early toxicity from TRM would eventually be surpassed by later deaths and/or organ failure from disease progression in the control arm, but this has yet to be proven. The peer-reviewed, published scientific research consists of retrospective analyses, small case studies, feasibility studies, and phase I/II trials that limit the ability to generalize findings to the AD population. However, a number of phase III clinical trials are ongoing. Nonstandard patient selection criteria, small patient populations, variability of conditioning regimens used for transplantation, and lack of randomization are reported limitations of many published studies. Although results of published studies are promising, in the absence of outcomes from well-designed RCTs published in peer-reviewed scientific literature, the role of HSCT for any AD has not yet been established. An early report described that 650 patients in Phase I and II clinical trials had received HSCT, and Phase III trials were merited, but considerable morbidity and mortality had been observed (Saccardi, 2004). An updated version of this report, covering 1,000 patients (including 200 in the U.S.), reported a declining mortality rate over time (Passweb, 2007). Sufficient experience with transplants by 2012 provided a basis for a guideline written by European experts, describing current and future HSCT protocols for autoimmune disease (Snowden, 2012). The current number of AD patients treated with HSCT worldwide now exceeds 2,000 (Rebeiro, 2016). There are only a few meta-analyses and systematic reviews on HSCT for AD. Two addressed Crohn s disease; one used only 33 cases, finding remission in 29 (Leung, 2006), while the other used 20 cases of inflammatory bowel disease, finding remission in 17 (Al-toma, 2014). A review of 35 polycythemia vera patients found no evidence basis for treating the disease with HSCT (Cario, 2009). Meta-analyses on HSCT for MS patients have been conducted. One evaluated a small number of MS patients undergoing HSCT, reporting that intermediate-conditioning regimens increased progressionfree survival compared to high-intensity conditioning regimens (Reston, 2011). Another suggested some clinical benefits of HSCT combined with immunotherapy, but cautioned that sample sizes are small and not always comparable (Li, 2016). MS has been described as the lead indication for HSCT treatment (Atkins, 2010), and is the most commonly-studied AD receiving HSCT in the medical literature. There are no controlled studies comparing HSCT with other therapies for MS or other autoimmune diseases (Pasquini, 2010). Numerous articles in the medical literature have addressed efficacy of HSCT for treating MS, including: 6

7 Improvements in relapse-free, progression-free, or MS activity-free survival (Burt, 2015; Atkins, 2016; Saccardi, 2006; Fassas, 2010) Improvements in Expanded Disability Status Scale (EDSS) scores (Burt, 2015; Shevchenko, 2008; Bowen, 2012) Reduction in number and volume of T2 lesions lesions (Burt, 2015; Mancardi, 2015; Shevchenko, 2008) Better responses when treatment commences early in the disease (Atkins, 2010) Reversal of neurological deficits (Burt, 2009) Despite these results, a consensus for using HSCT for MS is still lacking among experts, as the number of studies and subjects is insufficient. Policy updates: An additional 20 references were added. Most were recent publications or studies specifically on HSCT and multiple sclerosis. Summary of clinical evidence: Citation Atkins (2016) Clinical trial of long term control of MS after HSCT Burt (2015) HSCT outcomes for patients w relapsingremitting MS Atkins (2012) Content, Methods, Recommendations Key points: Phase 2 single-arm trials in Canada, MS patients with poor prognosis, ongoing disease, poor Expanded Disability Status Scale scores, n=24, median follow up 6.7 years Patients underwent chemotherapy, immune-depleting antibodies, HSCT MS activity free survival at 3 years = 69.6% With up to 13 years of follow-up after HSCT, no relapses occurred and no Gd enhancing lesions or new T2 lesions Described as first treatment to fully halt all detectable CNS inflammatory activity in MS patients for a prolonged period Key points: 145 patients with relapsing-remitting MS or secondary-progressive MS All treated with HSCT at same institution from , median follow up 2 years Significant improvement from pre-transplant to 2 years to 4 years in Expanded Disability Status scale (4.0 to 3.0 to 2.5); Neurologic Rating Scale improved (74.0 to 88.0 to 87.5); total quality of life scores improved (46 to 64, none available for 4 years); Four-year relapse-free survival =80%, progression-free survival = 87% T2 lesion volume decreased from pre transplant median of 8.57 cm3 to 5.74 at latest assessment (mean follow up 27 months) Key points: Review of HSCT progress in improving Since 1996, more than 1300 AD patients were registered by the European Group for Blood and Marrow Transplantation (EBMT) and almost 500 patients by the Center for 7

8 outcomes for persons with AD Sullivan KM (2010) Hematopoietic cell transplantation for autoimmune disease: updates from Europe and the United States Key points: International Blood and Marrow Transplant Research (CIBMTR). Autologous HCT is most commonly performed on patients with MS or SSc. Systemic lupus, Crohn's disease, type I diabetes, and JIA are other common indications. The paucity of controlled studies, the short-term toxicities, and the upcoming availability of second-generation biologic and targeted immunotherapies argues that perhaps HSCT for AID should be limited to clinical trials transplants for AD in Europe along with the three major multinational randomized trials for SSc (the ASTIS study), MS (the ASTIMS study), and Crohn's disease (the ASTIC study). Completed U.S. phase II studies of transplantation for severe SSc, SLE, and MS yield promising results. For individuals with SSc, there is dramatic improvement/resolution of dermal fibrosis and stabilization/improvement of pulmonary dysfunction, reported up to eight years after lymphoablative conditioning, and autologous HCT. Randomized phase III studies are recruiting U.S. subjects with SSc, MS and CD. In addition, nine other U.S. phase I and II trials are recruiting patients with AD for nonmyeloablative transplants from allogeneic HSC donors. Within several NIH sponsored trials there are ongoing immunologic, genomic, and mechanistic studies to further understand the molecular mechanisms of autoimmunity, immune regulation, and response to treatment. These clinical trials will provide scientists with insight into immunoregulatory pathways and clinicians with a context to weigh the progress and evidence in this evolving treatment for ADs. References Professional society guidelines/other: American Autoimmune Related Diseases Association, Inc. (AARDA American Autoimmune Related Diseases Association (AARDA) Web site. Accessed November 15, ECRI Institute. Immunoablative therapy with bone marrow or peripheral stem cell transplantation for multiple sclerosis [Evidence Report] Available at URL address: Accessed November 15, ECRI Institute. Immunoablative therapy with bone marrow or peripheral stem cell transplantation for rheumatoid arthritis and juvenile idiopathic arthritis [Evidence Report] Available at URL address: Accessed November 15, Freedman MS, Bar-Or A, Atkins HL, et al. The therapeutic potential of mesenchymal stem cell transplantation as a treatment for multiple sclerosis: consensus report of the International MSCT Study Group. Mult Scler. 2010;16(4): Hayes Inc. Autologous stem cell transplantation for systemic sclerosis. Lansdale PA: Hayes, Inc. 8

9 November 12, Accessed November 15, National Institute for Health and Clinical Excellence (NICE). Crohn's disease: Management in adults, children and young people. NICE Clinical Guideline No London, UK: National Institute for Health and Clinical Excellence (NICE); October National Health, Lung and Blood Institute (NHLBI). Polycythemia vera. Diseases and Conditions Index. Bethesda, MD: National Institutes for Health (NIH); revised March Accessed November 15, Snowden JA, Saccardi R, Allez M, et al. Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant. 2012;47(6): Tyndall A. Successes and Failures of Stem Cell Transplantation in Autoimmune Diseases American Society of Hematology. Web site. Accessed November 15, Peer-reviewed references: Al-toma A, Nijeboer P, Bouma G, Visser O, Mulder CJ. Hematopoietic stem cell transplantation for nonmalitnant gastrointestinal diseases. World J Gastroenterol. 2014;20(46): Atkins H. Hematopoietic SCT for the treatment of multiple sclerosis. Bone Marrow Transplant. 2010;45(12): Atkins HL, Muraro PA, van Laar JM, Pavletic SZ. Autologous hematopoietic stem cell transplantation for autoimmune disease--is it now ready for prime time? Biol Blood Marrow Transplant Jan; 18(1 Suppl):S Atkins HL, Bowman M, Allan D, et al. Immunoablation and autologous haematopoietic stem-cell transplantation for aggressive multiple sclerosis: a multicenter single-group phase 2 trial. Lancet. 2016;388(10044): Bowen JD, Kraft GH. Autologous hematopoietic cell transplantation following high-dose immunosuppressive therapy for advanced multiple sclerosis: long-term results. JAMA Neurol. 2015;72(2): Brinkman DM, de Kleer IM, ten Cate R, van Rossum MA, et al. Brinkman DM, et al. (2007) Autologous stem cell transplantation in children with severe progressive systemic or polyarticular 9

10 juvenile idiopathic arthritis: long-term follow-up of a prospective clinical trial. Arthritis Rheum Jul; 56(7): Burt RK, Balabanov R, Han X, et al. Association of nonmyeloablative hematopoietic stem cell transplantation with neurological disability in patients with relapsing-remitting multiple sclerosis. JAMA. 2015; 313(3): Burt RK, Marmont A, Oyama Y, et al. Randomized controlled trials of autologous hematopoietic stem cell transplantation for autoimmune disease: the evolution from myeloablative to lymphoablative transplant regimens. Arthritis Rheum. 2006; 54(12): Burt RK, Patel D, Thomas J, et al. The rationale behind autologous autoimmune hematopoietic stem cell transplant conditioning regimens: concerns over the use of total body irradiation in systemic sclerosis. Bone Marrow Transplant. 2004; 34(9): Burt RK, Testor A, Craig R, Cohen B, Suffit R, Barr W. Hematopoietic stem cell transplantation for autoimmune diseases: what have we learned? J Autoimmun May; 30(3): Burt RK, Loh Y, Cohen B, et al. Autologous non-myeloablative haemopoietic stem cell transplantation in relapsing-remitting multiple sclerosis: a phase I/II study. Lancet Neurol. 2009;8(3): Bjartmar C, Trapp BD. Axonal injury and disease progression in multiple sclerosis: stem cell therapy for autoimmune disease. Landes Bioscience. 2004; 34. Cario H, McMullin MF, Pahl HL. Clinical and hematological presentation of children and adolescents with polycythemia vera. Ann Hematol. 2009;88(8): Daikeler T, Kötter I, Bocelli Tyndall C, et al. EBMT Autoimmune disease working party. Haematopoietic stem cell transplantation for vasculitis including Behcet's disease and polychondritis: a retrospective analysis of patients recorded in the European Bone Marrow Transplantation and European League Against Rheumatism databases and a review of the literature. Ann Rheum Dis. 2007; 66(2): de Carvalho JF, Pereira RM, Gershwin ME. Hematopoietic cell transplants in autoimmunity Isr Med Assoc J Oct;11(10): Fassas A, Kimiskidis VK, Sakellari I, et al. Long-term results of stem cell transplantation for MS: a singlecenter experience. Neurology. 2011;76(12): Kotter I, Daikeler T, Amberger C, et al. Autologous stem cell transplantation of treatment-resistant systemic vasculitis--a single center experience and review of the literature. Clin Nephrol. 2005; 64(6):

11 Leung Y, Geddes M, Storek J, Panaccione R, Beck PL. Hematopoietic cell transplantation for Crohn s disease; is it time? World J Gastroenterol. 2006;12(41): Li C, Feng J, Chen S, He Y. Efficacy of hematopoietic stem cell for multiple sclerosis, and evidence based meta-analysis. Cell Mol Biol. 2016;30:62(4): Mancardi GL, Sormani MP, Gualandi F, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis: a phase II trial. Neurology. 2015;84(10): Mohyeddin Bonab M, Yazdanbakhsh S, Lotfi J, et al.does mesenchymal stem cell therapy help multiple sclerosis patients? Report of a pilot study.iran J Immunol. 2007; 4(1): Pasquini MC, Griffith LM, Arnold DL, et al. Hamatopoietic stem cell transplantation for multiple sclerosis: collaboration of the CIMTR and EMT to facilitate international clinical studies. Biol Blood marrow Transplant. 2010;16(8): Passweg J, Tyndall A. Autologous stem cell transplantation in autoimmune diseases. Semin Hematol. 2007;44(4): Rebeiro P, Moore J. The role of autologous haemopoietic stem cell transplantation in the treatment of autoimmune disorders. Intern Med J. 2016;46(1): Reston JT, Uhl S, Treadwell JR, Nash RA, Schoelles K. Autologous hematopoietic cell transplantation for multiple sclerosis: a systematic review. Mult Scler. 2011;17(2): Rosa SB, Voltarelli JC, Chies JA, Pranke P. The use of stem cells for the treatment of autoimmune disease. Braz J Med Biol Res. 2007; 40(12): Saccardi R, Tyndall A, Coghlan G, et al. Consensus statement concerning cardiotoxicity occurring during haematopoietic stem cell transplantation in the treatment of autoimmune diseases, with special reference to systemic sclerosis and multiple sclerosis. Bone Marrow Transplant. 2004;34(10): Saccardi R, Kozak T, Bocelli-Tyndall C, et al. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12(6): Shevchenko YL, Novik AA, Kuznetsov AN, et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Exp Hematol. 2008;36(8): Stellman JP, Sturner KH Ufer F, et al. Stem cell transplantation for multiple sclerosis. Hamburg experiences and state of international research. Nervenarzt. 2015;86(8):

12 Sullivan KM, Muraro P, Tyndall A. Hematopoietic cell transplantation for autoimmune disease: updates from Europe and the United States.Biol Blood Marrow Transplant Jan; 16(1 Suppl):S Tyndall A. Successes and Failures of Stem Cell Transplantation in Autoimmune Diseases American society of hematology doi: /asheducation ASH Education Book December 10, 2011 vol no CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor Hematopoietic progenitor cell (HPC); autologous transplantation ICD-10 Code Description Comments K90.0 Celiac sprue K50.90 Crohn s disease E05.00 Grave s disease M08.90 Juvenile idiopathic arthritis G36.0 Neuromyelitis optica D51.0 Pernicious anemia M05.60 Rheumatoid arthritis M35.00 Sjogren s Syndrome M32.10 System lupus erythematosus M34.9 Systemic sclerosis (scleroderma) I77.6 Systemic vasculitis E10.8 Type I Diabetes Mellitus K51.90 Ulcerative colitis 12

13 HCPCS Level II None Description Comments 13