For individuals with non-Hodgkin lymphoma (NHL) B-cell subtypes considered aggressive (except mantle cell lymphoma), either allogeneic hematopoietic cell transplantation (HCT) using a myeloablative conditioning regimen or autologous HCT may be considered medically necessary:
as salvage therapy for individuals who do not achieve a complete remission (CR) after first-line treatment (induction) with a full course of standard-dose chemotherapy;
to achieve or consolidate a CR for those in a chemosensitive first or subsequent relapse; or
to consolidate a first CR in individuals with diffuse large B-cell lymphoma, with an age-adjusted International Prognostic Index score that predicts a high- or high-intermediate risk of relapse.
For individuals with mantle cell lymphoma:
Autologous HCT may be considered medically necessary to consolidate a first remission.
Allogeneic HCT, with myeloablative or reduced-intensity conditioning, may be considered medically necessary as salvage therapy.
Autologous HCT is considered investigational as salvage therapy.
Allogeneic HCT is considered investigational to consolidate a first remission.
For individuals with NHL B-cell subtypes considered indolent, either allogeneic HCT using a myeloablative conditioning regimen or autologous HCT may be considered medically necessary:
as salvage therapy for individuals who do not achieve CR after first-line treatment (induction) with a full course of standard-dose chemotherapy; or
to achieve or consolidate CR for those in a first or subsequent chemosensitive relapse, whether or not their lymphoma has transformed to a higher grade.
Either autologous HCT or allogeneic HCT is considered investigational:
as initial therapy (ie, without a full course of standard-dose induction chemotherapy) for any NHL;
to consolidate a first CR for individuals with diffuse large B-cell lymphoma and an International Prognostic Index score that predicts a low- or low-intermediate risk of relapse;
to consolidate a first CR for those with indolent NHL B-cell subtypes.
For individuals with mature T-cell or natural killer cell (peripheral T-cell) neoplasms:
Autologous HCT may be considered medically necessary to consolidate a first CR in high-risk subtypes (see Policy Guidelines section).
Autologous or allogeneic HCT (with myeloablative or reduced-intensity conditioning) may be considered medically necessary as salvage therapy.
Allogeneic HCT is considered investigational to consolidate a first remission.
For individuals with hepatosplenic T-cell lymphoma:
Allogenic HCT may be considered medically necessary to consolidate a first CR or partial response.
Autologous HCT may be considered medically necessary to consolidate a first response if a suitable donor is not available or for individuals who are ineligible for allogeneic HCT.
Autologous or allogeneic HCT as initial therapy (i.e., without a full course of standard-dose induction chemotherapy) is considered investigational.
Reduced-intensity conditioning with allogeneic HCT may be considered medically necessary as a treatment of NHL in individuals who meet criteria for an allogeneic HCT but who do not qualify for a myeloablative allogeneic HCT (see Policy Guidelines section).
Tandem transplants are considered investigational to treat patients with any stage, grade, or subtype of NHL.
Note: Small lymphocytic lymphoma may be considered a node-based variant of chronic lymphocytic leukemia. Therefore, small lymphocytic lymphoma is considered along with chronic lymphocytic leukemia in evidence review 08.001.047. Lymphoplasmacytic lymphoma/Waldenström macroglobulinemia is considered in evidence review 08.001.054.
