Autologous or allogeneic hematopoietic cell transplantation (HCT) is considered investigational as a treatment of autoimmune diseases, including, but not limited to, the following:
multiple sclerosis
systemic lupus erythematosus
juvenile idiopathic or rheumatoid arthritis
chronic inflammatory demyelinating polyneuropathy
type 1 diabetes.
Autologous HCT is considered medically necessary as a treatment of systemic sclerosis (scleroderma) if all of the following conditions are met:
adult individuals <60 years of age; AND maximum duration of condition of 5 years; AND modified Rodnan skin scores>15; AND
internal organ involvement as noted in the Policy Guidelines; AND
history of <6 months treatment with cyclophosphamide; AND no active gastric antral vascular ectasia; AND do not have any exclusion criteria as noted in the Policy Guidelines. Autologous HCT as a treatment of systemic sclerosis/scleroderma not meeting the above criteria is considered investigational.
