Name of Policy:

Placental/Umbilical Cord Blood as a Source of Stem Cells

Policy #: 439 Category: Medical Latest Review Date: September 2013 Policy Grade: A

Background/Definitions:
As a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage. The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage: 1. The technology must have final approval from the appropriate government regulatory bodies; 2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes; 3. The technology must improve the net health outcome; 4. The technology must be as beneficial as any established alternatives; 5. The improvement must be attainable outside the investigational setting. Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are: 1. In accordance with generally accepted standards of medical practice; and 2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patients illness, injury or disease; and 3. Not primarily for the convenience of the patient, physician or other health care provider; and 4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patients illness, injury or disease.

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Description of Procedure or Service:

This policy addresses the collection, storage and transplantation of placental/umbilical cord blood (cord blood) as a source of stem cells for allogeneic and autologous stem-cell transplantation. Potential indications for use of cord blood are included in the disease-specific reference policies. A variety of malignant diseases and nonmalignant bone marrow disorders are treated with myeloablative therapy followed by infusion of allogeneic stem and progenitor cells collected from immunologically compatible donors, either from family members or an unrelated donor identified through a bone marrow donor bank. In some cases, a suitable donor is not found. Blood harvested from the umbilical cord and placenta shortly after delivery of neonates contains stem and progenitor cells capable of restoring hematopoietic function after myeloablation. This cord blood has been used as an alternative source of allogeneic stem cells. Cord blood is readily available and is thought to be antigenically naive, thus hopefully minimizing the incidence of graft-versus-host disease (GVHD) and permitting the broader use of unrelated cord blood transplants. Unrelated donors are typically typed at low resolution for HLA-A and B and at high resolution only for HLA-DR; HLA matching at four of six loci is considered acceptable. Under this matching protocol, an acceptable donor can be identified for almost any patient. Several cord blood banks have now been developed in Europe and in the U.S. The U.S. Food and Drug Administration (FDA) requires licensing of establishments and their products for unrelated-donor allogeneic transplant of minimally manipulated placental and umbilical cord blood stem cells. Facilities that prepare cord blood units only for autologous or related-donor transplants are required to register and list their products, adhere to Good Tissue Practices issued by the FDA, and use applicable processes for donor suitability determination. Other cord blood banks are offering the opportunity of collecting and storing a neonates cord blood for some unspecified future use in the unlikely event that the child develops a condition that would require autologous transplantation. In addition, some cord blood is collected and stored from a neonate for use by a sibling in whom an allogeneic transplant is anticipated due to a history of leukemia or other condition requiring allogeneic transplant. As with any biologic product, there are issues unique to cord blood as an unrelated donor source; some of these are as follows:

Cell dose available is much closer to the minimum needed for engraftment Interbank variability in the quantification of hematopoietic potential Donors who may have hematologic/immunologic disorders may not have manifested their disease at the time of donation or follow-up Units may have been banked years earlier at a time when the collection and storage process may not have reflected current accreditation standards, and, The initial product characterization at the end of processing may not reflect the product at the time of release due to freeze, storage, or transport insults.

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For the reasons cited above, instituting international standards and accreditation for cord blood banks is critical. This will assist transplant programs in knowing whether individual banks have important quality control measures in place to address such issues as monitoring cell loss, change in potency, and prevention of product mix-up. Two major organizations are working toward these accreditation standards; NetCord/FACT and the American Association of Blood Banks (AABB). NetCord, Foundation for the Accreditation of Cellular Therapy (FACT) has developed and implemented a program of voluntary inspection and accreditation for cord blood banking. In September 2012, NetCord and FACT released the fifth edition of international standards for cord blood collection, banking and release. The voluntary program includes standards for collection, testing, processing, storage, and release of cord blood products. As of August 2013, 27 blood banks in the U.S. have been accredited, along with 45 international sites. The U.S. Food and Drug Administration intends to regulate cord blood banking by requiring Biologic License Applications and/or Investigational New Drug applications by October 2011 for any bank that will supply units to patients in the United States. With the international exchange of cord blood units being integral to the availability of a matched unit, it is unclear how this change will affect the practice of acquiring cord blood units. It is also important to note umbilical cord blood (UCB) samples are not routinely typed for private banking. This makes it difficult to search for unrelated human leukocyte antigen (HLA)matched donors in private banks, or to transfer units into a public bank from a private bank.

Policy:
Transplantation of cord blood stem cells from related or unrelated donors meets Blue Cross and Blue Shield of Alabamas medical criteria for coverage in patients with an appropriate indication for allogeneic stem-cell transplant. Transplantation of cord blood stem cells from related or unrelated donors does not meet Blue Cross and Blue Shield of Alabamas medical criteria and is considered investigational in all other situations. Collection and storage of cord blood from a neonate meets Blue Cross and Blue Shield of Alabamas medical criteria for coverage when an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the possible need for allogeneic transplant. Prophylactic collection and storage of cord blood from a neonate does not meet Blue Cross and Blue Shield of Alabamas medical criteria for coverage when proposed for some unspecified future use as an autologous stem-cell transplant in the original donor, or for some unspecified future use as an allogeneic stem-cell transplant in a related or unrelated donor. Please refer to the reference policies for specific conditions/diseases that have patient selection criteria regarding situations for which allogeneic stem-cell transplantation may be considered medically necessary.
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Blue Cross and Blue Shield of Alabama does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. Blue Cross and Blue Shield of Alabama administers benefits based on the members' contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

Key Points:
This policy was originally based on TEC Assessments in 1996 and 2001 that focused on the use of placental/umbilical cord blood in children and adults, respectively. The most recent update via MEDLINE was for the period September 2012 through July 25, 2013. Related cord blood transplant The first cord blood transplant was a related cord blood transplant for a child with Fanconis anemia. After the success of this initial transplant, approximately 60 others were performed in the matched-sibling setting. The results, demonstrating that cord blood contained sufficient numbers of hematopoietic stem and progenitor cells to reconstitute a pediatric patient, were reported to a volunteer international registry. A lower incidence of acute and chronic graftversus-host disease (GVHD) when cord blood, as compared with bone marrow, was used as the source of donor cells was also observed. This led to the hypothesis that cord blood could be banked and used as a source of unrelated donor cells, possibly without full HLA matching. Unrelated cord blood transplant In 1996, outcome data from the first 25 unrelated cord blood transplants completed at Duke University were reported. This study concluded that cord blood contained sufficient numbers of stem cells and progenitor cells to reconstitute the marrow of children who underwent myeloablative treatments, without full human leukocyte antigen (HLA) matching between donor and recipient. Since this time, research has been ongoing to study the effectiveness of placental/umbilical cord blood for the treatment of various conditions The first prospective study of unrelated cord blood transplant was the Cord Blood Transplantation study (COBLT) from 1997-2004. COBLT was designed to examine the safety of unrelated cord blood transplantation in infants, children, and adults. In children with malignant and nonmalignant conditions, two-year event-free survival was 55% in children with high-risk malignancies and 78% in children with nonmalignant conditions. Across all groups, the cumulative incidence of engraftment by day 42 was 80%. Engraftment and survival were adversely affected by lower cell doses, pretransplant cytomegalovirus seropositivity in the recipient, non-European ancestry, and higher HLA mismatching. This slower engraftment leads to longer hospitalizations and greater utilization of medical resources. In a retrospective multicenter study of 541 children with acute leukemia, rates of neutrophil recovery at day 60 were statistically different: 96% versus 80% for those receiving unrelated bone marrow and unrelated cord blood, respectively. In the COBLT study,
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outcomes in adults were inferior to the outcomes achieved in children. This study also established three new cord blood banks and standard operating procedures addressing donor recruiting and screening, cord blood collection, processing, testing, cryopreservation, storage, and thawing for transplantation. In 2012, Zhang and colleagues published a meta-analysis of studies comparing unrelated donor cord blood transplantation to unrelated donor bone marrow transplantation in patients with acute leukemia. The authors identified seven studies with a total of 3,389 patients. Pooled rates of engraftment failure (n=5 studies) were 127 events in 694 patients (18%) in the cord blood transplantation group and 57 events in 951 patients (6%) in bone marrow transplantation patients. The rate of engraftment graft failure was significantly higher in cord blood transplantation recipients, p<0.0001. However, rates of acute GVHD were significantly lower in the group receiving cord blood transplantation. Pooled rates of GVHD (n=7 studies) were 397 of 1,179 (34%) in the cord blood group and 953 of 2,189 (44%) in the bone marrow group, p<0.0001. Relapse rates, reported in all studies, did not differ significantly between groups. Several survival outcomes including overall survival, leukemia-free survival and non-relapse mortality favored the bone marrow transplantation group. A 2013 study compared survival rates after bone marrow transplantation or unrelated cord blood transplantation in patients older than age 50 years with acute myelogenous leukemia who received reduced-intensity conditioning. The adjusted three-year overall survival rate was 51% (95% confidence interval [CI]: 38-63%) after related donor bone marrow transplantation, 53% (95% CI: 28-78%) after unrelated donor bone marrow transplantation and 45% (95% CI: 31-58) after unrelated donor cord blood transplantation; the difference among groups was not statistically different, p=0.73. In addition to the above studies, there have been numerous retrospective and registry studies. These have generally found that unrelated cord blood transplantation is effective in both children and adults with hematologic malignancies and children with a variety of nonmalignant conditions. The majority of cord blood transplants have been mismatched at one or two HLA loci. A 2007 retrospective comparative analysis from the Center for International Blood and Marrow Transplant Research compared outcomes after unrelated cord blood versus unrelated bone marrow transplant. This study showed similar five-year leukemia-free survival for those receiving allele-matched marrow and those who received unrelated cord blood with a one or two antigen mismatch. A minimum cell dose of 2.53.0 X 107 nucleated cells/kg in the cord blood has been associated with superior clinical outcome. More recently, transplantation of two umbilical cord blood units (also known as double unit transplants) have been evaluated as a strategy to overcome cell-dose limitations with one cord blood unit in older and heavier patients. Initial experience at the University of Minnesota has shown that using two units of cord blood for a single transplant in adults improved rates of engraftment and overall survival. Pilot studies have shown engraftment being achieved by at least 90%, with overall survival at one year ranging from 6080%, depending on the initial disease, comorbidities, and disease status at the time of transplant. In 2013, Scaradavou and colleagues reported a retrospective analysis using data from the Center for International Blood and Marrow Transplant Research (CIBMTR) and the U.S.-based National Cord Blood Program. . The authors reported data on adults with acute leukemia who received one (n=106) or two (n=303) umbilical cord blood units. All units used for single transplantation contained a
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minimum cell dose of 2.53.0 X 107 nucleated cells/kg. For the double transplants, the two units combined contained more than 2.53.0 X 107 nucleated cells/kg, but in about half of cases, individual units contained less than the minimum amount required. In analyses adjusting for factors associated with outcomes, rates of transplantation-related mortality (hazard ratio [HR]: 0.91, p=0.63), relapse (HR: 0.90, p=0.64) and overall mortality (HR: 0.93, p=0.62) were similar in the groups that received single and double transplantations. For patients treated in the earlier period, 2002-2004, there was a significantly higher risk of Grade 2 to 4 acute GVHD in recipients of double cord blood units (HR: 6.14, 95% CI: 2.54-14.87, p<0.001). In the later period, 2004-2009, rates of Grade 2 to 4 acute GVHD did not differ significantly between groups (HR: 1.69, 95% CI: 0.68-4.18, p=0.30). Several prospective randomized controlled trials (RCTs) comparing the efficacy and safety of single and double cord blood unit grafts are ongoing. Autologous cord blood transplant Data regarding the use of cord blood for autologous stem-cell transplantation are quite limited. However, blood banks are available for collecting and storing a neonates cord blood for a potential future use. A position paper from the American Academy of Pediatrics noted that there is no evidence of the safety or effectiveness of autologous cord blood transplantation for treatment of malignant neoplasms. This report comments on evidence demonstrating the presence of DNA mutations in cord blood from children who subsequently develop leukemia. In addition, a survey of pediatric hematologists noted few transplants have been performed using cord blood stored in the absences of a known indication. Thus the practice of collecting and storing cord blood for a potential future use is considered not medically necessary. Summary Cord blood transplantation offers some clear advantages over other sources of allogeneic stem cells; the most significant of these is the ability to perform a successful transplant from a unrelated donor with one or two HLA mismatches. Cord blood is also more readily available, generally within one-two weeks. Collection of the cells is painless, which facilitates recruitment providing for a more ethnically diverse pool. Current limitations include small inventories, units with low cell doses, and too few donors to provide five of six and six of six matches for all patients in need. There is some evidence from retrospective studies that double umbilical cord blood transplants may be a safe and effective alternative to single-unit transplants and several prospective RCTs are underway. Longer hospital stays and higher utilization of medical resources are a consequence of slower engraftment when cord blood is used. Even with these limitations, cord blood is an important source of stem cells, increasing the access to allogeneic stem-cell transplantation for many patients. Use in this situation may be considered medically necessary. However, the routine collection and storage of cord blood for possible future use is not considered current standard medical care and has not been shown to improve outcomes. As a result, routinely collecting and storing cord blood for a potential future use is considered not medically necessary. Technology Assessments, Guidelines and Position Statements The American Society for Blood and Marrow Transplantation, published recommendations related to the banking of umbilical cord blood:
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Public banking of cord blood is encouraged where possible. Storage of cord blood for autologous (i.e., personal) use is not recommended. Family member banking (collecting and storing cord blood for a family member) is recommended when there is a sibling with a disease that may be successfully treated with an allogeneic transplant. Family member banking on behalf of a parent with a disease that may be successfully treated with an allogeneic transplant is only recommended when there are shared HLA antigens between the parents

Key Words:
Cord Blood as a Source of Stem Cells, Transplantation, Placental and Umbilical Cord Blood as a Source of Stem Cells, cord blood, stem cell transplant, placental blood, umbilical cord blood

Approved by Governing Bodies:

Through the National Marrow Donor Programs Related Donor Cord Blood Program, eligible families within the U.S. can collect and store their neonates cord blood unit free of charge. When the stored unit is transplanted, a fee is charged. A family is considered eligible if: The sibling of the neonate has been diagnosed with a disease treatable by a related cord blood transplant; The neonate does not have the same disease as the affected biological sibling (determined after birth); The affected sibling and the neonate have the same biological parents; or if: An affected biological parent is enrolled in a clinical or research trial that would accept a haploidentical, related, allogeneic cord blood unit as a treatment option.

Benefit Application:
Coverage is subject to members specific benefits. Group specific policy will supersede this policy when applicable. ITS: Home Policy provisions apply FEP: Special benefit consideration may apply. Refer to members benefit plan.

Current Coding:
HCPCS Codes: S2140 Cord blood harvesting for transplantation, allogenic S2142 Cord blood derived stem-cell transplantation, allogenic 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
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rehabilitative services; and the number of days of pre- and posttransplant care in the global definition

References:
1. American Academy of Pediatrics Section of Hematology/Oncology; American Academy of Pediatrics Section on Allergy/Immunology; Lubin BH, Shearer WT. Cord blood banking for potential future transplant. Pediatrics 2007; 119(1):165-70. 2. American Association of Blood Banks (AABB). AABB Accredited Cord Blood (CB) Facilities Available online at: www.aabb.org/sa/facilities/celltherapy/Pages/CordBloodAccrFac.aspx. Last accessed August, 2013. 3. Ballen KK, Barker JN, Stewart SK et al. Collection and preservation of cord blood for personal use. Biol Blood Marrow Transplant 2008; 14(3):356-63. 4. Barker JN, Byam C, Scaradavou A. How I treat: the selection and acquisition of unrelated cord blood grafts. Blood 2011; 117(8):2332-9. 5. Barker JN, Weisdorf DJ, DeFor TE et al. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood 2005; 105(3):1343-47. 6. Blue Cross Blue Shield Association. Technology Evaluation Center (TEC) Assessment; Placental and Umbilical Cord Blood as a Source of Stem Cell for Hematopoietic Support.1996: Volume 16,Tab 17. 7. Blue Cross Blue Shield Association. Technology Evaluation Center (TEC) Assessment; 2001: Tab 17. 8. Broxmeyer HE, Douglas GW, Hangoc G et al. Human umbilical cord blood as a potential source of transplantable hematopoietic stem/progenitor cells. Proc Natl Acad Sci U S A 1989; 86(10):3828-32. 9. Fraser J, Cairo MS, Wagner E et al. Cord Blood Transplantation Study (COBLT): cord blood bank standard operating procedures. J Hematother 1998; 7(6):521-61. 10. Gluckman E, Broxmeyer HA, Auerbach AD et al. Hematopoietic reconstitution in a patient with Fanconi's anemia by means of umbilical-cord blood from an HLA-identical sibling. N Engl J Med 1989; 321(17):1174-8. 11. Gluckman E, Rocha V, Boyer-Chammard A et al. Outcome of cord-blood transplantation from related and unrelated donors. N Engl J Med 1997; 337(6):373-81. 12. Godley LA, van Besien K. The next frontier for stem cell transplantation finding a donor for all. JAMA 2010; 303(14):1421-22. 13. Kurtzberg J, Cairo MS, Fraser JK et al. Results of the cord blood transplantation study (COBLT) study unrelated donor banking program. Transfusion 2005; 45(6):842-55. 14. Kurtzberg J, Laughlin M, Graham ML et al. Placental blood as a source of hematopoietic stem cells for transplantation into unrelated recipients. N Engl J Med 1996; 335(3):157-66. 15. Kurtzberg J, Prasad VK, Carter SL et al. Results of the Cord Blood Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematological malignancies. Blood 2008; 112(10):4319-327. 16. Kurtzberg J. Update on umbilical cord blood transplantation. Curr Opin Pediatr 2009; 21(1):22-9.
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Martin PL, Carter SL, Kernan NA et al. Results of the cord blood transplantation study (COBLT): outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with lysosomal and peroxisomal storage diseases. Biol Blood Marrow Transplant 2006; 12(2):184-94. 18. Mayani H, Lansdorp PM. Biology of human umbilical cord blood-derived stem/progenitor cells. Stem Cells 1998; 16(3):153-65. 19. Medical Policy Reference Manual. Placental/Umbilical Cord Blood as a Source of Stem Cells. 7.01.50. 20. NetCord-FACT. International standards for cord blood collection banking and release of information accreditation manual- Fifth Edition. September 2012. Available online at: www.factwebsite.org/uploadedFiles/FACT_News/Draft%205th%20Edition%20NetCordFACT%20Cord%20Blood%20Accreditation%20Manual.09.04.12.pdf. Last accessed August, 2013. 21. Peffault de Latour R, Brunstein CG, Porcher R et al. Similar Overall Survival Using Sibling, Unrelated Donor, and Cord Blood Grafts after Reduced-Intensity Conditioning for Older Patients with Acute Myelogenous Leukemia. Biol Blood Marrow Transplant 2013. 22. Prasad VK, Kurtzberg J. Emerging trends in transplantation of inherited metabolic diseases. Bone Marrow Transplant 2008; 41(2):99-108. 23. Rao M, Ahrlund-Richter L, Kaufman DS. Concise review: Cord blood banking, transplantation and induced pluripotent stem cell: success and opportunities. Stem Cells 2012; 30(1):55-60. 24. Rocha V, Cornish J, Sievers EL et al. Comparison of outcomes of unrelated bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood 2001; 97(10):2962-71. 25. Rubinstein P, Carrier C, Scaradavou A et al. Outcomes among 562 recipients of placentalblood transplants from unrelated donors. N Engl J Med 1998; 339(22):1565-77. 26. Scaradavou A, Brunstein CG, Eapen M et al. Double unit grafts successfully extend the application of umbilical cord blood transplantation in adults with acute leukemia. Blood 2013; 121(5):752-8. 27. Sponsored by Medical College of Wisconsin. Single Versus Double Umbilical Cord Blood Transplantation in Children With High Risk Leukemia and Myelodysplasia (BMT CTN 0501) (NCT00412360). Available online at: www.clinicaltrials.gov. Last accessed August, 2013. 28. Sponsored by Assistance Publique Hopitaux De Marseille. A Study Comparing Single Versus Double Umbilical Cord Blood Transplantation in the Young With Acute Leukemia Remission (NCT01067300). Available online at: www.clinicaltrials.gov. Last accessed August, 2013. 29. Thornley I, Eapen M, Sung L et al. Private cord blood banking: Experiences and views of pediatric hematopoietic cell transplantation physicians. Pediatrics 2009; 123(3):1011-17. 30. U.S. Food and Drug Administration. Guidance for Industry: Minimally manipulated, unrelated allogeneic placental/umbilical cord blood intended for hematopoietic reconstitution for specified indications. Available online at: www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInform ation/Guidances/Blood/UCM187144.pdfUH. Accessed May 2012.

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31.

32. 33.

Wagner JE, Rosenthal J, Sweetman R et al. Successful transplantation of HLA-matched and HLA-mismatched umbilical cord blood from unrelated donors: analysis of engraftment and acute graft-versus-host disease. Blood 1996; 88(3):795-802. Wall DA. Regulatory issues in cord blood banking and transplantation. Best Pract Res Clin Haematol 2010; 23(2):171-7. Zhang H, Chen J, Que W. A meta-analysis of unrelated donor umbilical cord blood transplantation versus unrelated donor bone marrow transplantation in acute leukemia patients. Biol Blood Marrow Transplant 2012; 18(8):1164-73.

Policy History:
Medical Policy Group, September 1998 (3) Medical Policy Group, January 2003 (3) Medical Policy Group, June 2010 (2) Medical Policy Administration Committee, July 2010 Available for comment July 2-August 16, 2010 Medical Policy Group, May 2012 (4): Policy unchanged. Updated Description and References. Medical Policy Group, January 2013 (4): Update to Description, Key Points, and References Medical Policy Panel, September 2013 Medical Policy Group, September 2013 (3): Updates to Description, Key Points and References; no change in policy statement
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a caseby-case basis according to the terms of the members plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment. This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shields administration of plan contracts.

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