Description
Myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN) refer to a heterogeneous group of clonal hematopoietic disorders with the potential to transform into acute myelocytic leukemia. Allogeneic hematopoietic cell transplantation (allo-HCT) has been proposed as a curative treatment option for patients with these disorders

Background
Myelodtysplastic Syndromes
MDS can occur as a primary (idiopathic) disease or can be secondary to cytotoxic therapy, ionizing radiation, or other environmental insults. Chromosomal abnormalities are seen in 40% to 60% of patients, frequently involving deletions of chromosome 5 or 7 or an extra chromosome as in trisomy 8. Most MDS diagnoses occur in individuals older than age 55 to 60 years, with an age-adjusted incidence of 62% among individuals older than age 70 years. Patients succumb either to disease progression to acute myeloid leukemia (AML) or to complications of pancytopenias. Patients with higher blast counts or complex cytogenetic abnormalities have a greater likelihood of progressing to AML than do other patients.

MDS Classification and Prognosis
The French-American-British system was used to classify MDS into five subtypes: (1) refractory anemia; (2) refractory anemia with ringed sideroblasts; (3) refractory anemia with excess blasts; (4) refractory anemia with excess blasts in transformation; and (5) chronic myelomonocytic leukemia. The French-American-British system was supplanted by that of the World Health Organization (WHO), which records the number of lineages in which dysplasia is seen (unilineagevs multilineage), separates the 5q-syndrome, and reduces the threshold maximum blast percentage for the diagnosis of MDS from 30% to 20%.

The most commonly used prognostic scoring system for MDS is the International Prognostic Scoring System (IPSS), which groups patients into one of four prognostic categories based on the number of cytopenias, cytogenetic profile, and the percentage of blasts in the bone marrow. This system underweights the clinical importance of severe, life-threatening neutropenia and thrombocytopenia in therapeutic decisions and does not account for the rate of change in critical parameters (e.g., peripheral blood counts, blast percentage). However, the IPSS has been useful in a comparative analysis of clinical trial results and its utility confirmed at many institutions. An updated 5-category IPSS has been proposed for prognosis in patients with primary MDS or secondary AML to account for chromosomal abnormalities frequently seen in MDS.¹ This system stratifies patients into five categories: very poor, poor, intermediate, good, and very good. There has been an investigation into using the 5-category IPSS to better characterize risk in MDS. A second prognostic scoring system incorporates the WHO subgroup classification that accounts for blast percentage, cytogenetics, and severity of cytopenias as assessed by transfusion requirements. The WHO classification-based Prognostic Scoring System uses a 6-category system, which allows more precise prognostication of overall survival (OS) duration, as well as risk for progression to AML. This system is not yet in widespread use in clinical trials.

MDS Treatment
Treatment of nonprogressing MDS has involved best supportive care, including red blood cell and platelet transfusions and antibiotics. Active therapy was given only when MDS progressed to AML or resembled AML with severe cytopenias. An array of therapies are now available to treat MDS, including hematopoietic growth factors (e.g., erythropoietin, darbepoetin, granulocyte colony-stimulating factor), transcriptional-modifying therapy (e.g., Food and Drug Administration‒approved hypomethylating agents, nonapproved histone deacetylase inhibitors), immunomodulators (e.g., lenalidomide, thalidomide, antithymocyte globulin, cyclosporine A), low-dose chemotherapy (e.g., cytarabine), and allogeneic hematopoietic cell transplantation (allo-HCT). Given the spectrum of treatments available, the goal of therapy must be decided upfront whether it is to improve anemia, thrombocytopenia, or neutropenia, to eliminate the need for red blood cell transfusion, to achieve complete remission, or to cure the disease.

Allo-HCT is the only approach with curative potential, but its use is governed by patient age, performance status, medical comorbidities, the patient’s risk preference, and severity of MDS at presentation. Allo-HCT is discussed in more detail in a subsequent section.

Chronic Myeloproliferative Neoplasms
Chronic MPN are clonal bone marrow stem cell disorders; as a group, approximately 8,400 MPN are diagnosed annually in the United States. Like MDS, MPN primarily occurs in older individuals, with approximately 67% reported in patients aged 60 years and older.

MPN are characterized by the slow but progressive expansion of a clone of cells with the potential evolution into a blast crisis similar to AML. MPN share a common stem cell‒derived clonal heritage, with phenotypic diversity attributed to abnormal variations in signal transduction as the result of a spectrum of variants that affects protein tyrosine kinases or related molecules. The unifying characteristic common to all MPN is effective clonal myeloproliferation resulting in peripheral granulocytosis, thrombocytosis, or erythrocytosis that is devoid of dyserythropoiesis, granulocytic dysplasia, or monocytosis.

MPN Classification
The WHO (2008) classification scheme replaced the term chronic myeloproliferative disorder with the term myeloproliferative neoplasm. MPN are a subdivision of myeloid neoplasms that includes four classic disorders: chronic myeloid leukemia, polycythemia vera, essential thrombocytopenia, and primary myelofibrosis. The WHO classification also includes chronic neutrophilic leukemia, chronic eosinophilic leukemia/hypereosinophilic syndrome, mast cell disease, and MPN unclassifiable.

MPN Treatment
In indolent, nonprogressing cases, therapeutic approaches are based on relief of symptoms. Supportive therapy may include prevention of thromboembolic events. Hydroxyurea may be used in cases of high-risk essential thrombocytosis and polycythemia vera, and intermediate- and high-risk primary myelofibrosis.

The Food and Drug Administration (2011) approved the orally administered selective Janus kinase 1 and 2 inhibitor ruxolitinib for the treatment of intermediate- or high-risk myelofibrosis. Ruxolitinib has been associated with improved OS, spleen size, and symptoms of myelofibrosis compared with placebo.² The COMFORT-II trial (2013) compared ruxolitinib with best available therapy in patients who had intermediate- and high-risk myelofibrosis, and demonstrated improvements in spleen volume and OS.³ In a randomized trial comparing ruxolitinib with best available therapy (including antineoplastic agents, most commonly hydroxyurea, glucocorticoids) with no therapy for treatment of myelofibrosis, Harrison et al. (2012) reported improvements in spleen size and quality of life, but not OS.⁴

Myeloablative allo-HCT has been considered the only potentially curative therapy, but because most patients are of advanced age with attendant comorbidities, its use is limited to those who can tolerate the often-severe treatment-related adverse events of this procedure. However, the use of reduced-intensity conditioning (RIC) of conditioning regimens for allo-HCT has extended the potential benefits of this procedure to selected individuals with these disorders. Allo-HCT is discussed in more detail in the next section.

Hematopoietic Cell Transplantation
Hematopoietic stem cells may be obtained from the transplant recipient (autologous HCT) or from a donor (allo-HCT). They can be harvested from bone marrow, peripheral blood, or umbilical cord blood shortly after delivery of neonates. Although cord blood is an allogeneic source, the stem cells in it are antigenically “naive” and thus are associated with a lower incidence of rejection or graft-versus-host disease. Cord blood is discussed in greater detail in evidence review 7.01.50.

Immunologic compatibility between infused hematopoietic stem cells and the recipient is not an issue in autologous HCT. However, immunologic compatibility between donor and patient is critical for achieving a good outcome of allo-HCT. Compatibility is established by typing of human leukocyte antigen (HLA) using cellular, serologic, or molecular techniques. HLA refers to the tissue type expressed at the HLA-A, -B, and -DR loci on each arm of chromosome 6. Depending on the disease being treated, an acceptable donor will match the patient at all or most of the HLA loci.

Conventional Preparative Conditioning for HCT
The conventional (“classical”) practice of allo-HCT involves administration of cytotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to destroy endogenous hematopoietic capability in the recipient. The beneficial treatment effect of this procedure is due to a combination of initial eradication of malignant cells and a subsequent graft-versus-malignancy effect that develops after engraftment of allogeneic stem cells within the patient’s bone marrow space. While the slower graft-versus-malignancy effect is considered to be the potentially curative component, it may be overwhelmed by extant disease without the use of pretransplant conditioning. However, intense conditioning regimens are limited to patients who are sufficiently fit medically to tolerate substantial adverse events that include pre-engraftment opportunistic infections secondary to loss of endogenous bone marrow function and organ damage and failure caused by the cytotoxic drugs. Furthermore, in any allo-HCT, immune suppressant drugs are required to minimize graft rejection and graft-versus-host disease, which also increases the susceptibility of the patient to opportunistic infections.

Reduced-Intensity Conditioning for Allo-HCT
RIC refers to the pretransplant use of lower doses or less intense regimens of cytotoxic drugs or radiation than are used in conventional full-dose myeloablative conditioning treatments. The goal of RIC is to reduce disease burden and to minimize as much as possible associated treatment-related morbidity and nonrelapse mortality in the period during which the beneficial graft-versus-malignancy effect of allogeneic transplantation develops. Although the definition of RIC remains arbitrary, with numerous versions employed, all seek to balance the competing effects of nonrelapse mortality and relapse due to residual disease. RIC regimens can be viewed as a continuum in effects, from nearly totally myeloablative to minimally myeloablative with lymphoablation, and intensity tailored to specific diseases and patient condition. Patients who undergo RIC with allo-HCT initially demonstrate donor cell engraftment and bone marrow mixed chimerism. Most will subsequently convert to full-donor chimerism, which may be supplemented with donor lymphocyte infusions to eradicate residual malignant cells. For this evidence review, RIC will refer to all conditioning regimens intended to be nonmyeloablative, as opposed to fully myeloablative (conventional) regimens.

Regulatory Status
The U.S. Food and Drug Administration regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under Code of Federal Regulation (CFR) title 21, parts 1270 and 1271. Hematopoietic stem cells are included in these regulations.

Related Policies
70150 Placental and Umbilical Cord Blood as a Source of Stem Cells
80126 Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia
80130 Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia

Policy
Myeloablative allogeneic hematopoietic cell transplantation (allo-HCT) may be considered MEDICALLY NECESSARY as a treatment of

• myelodysplastic syndromes (see Policy Guidelines section) or 
• myeloproliferative neoplasms (see Policy Guidelines section).

Reduced-intensity conditioning allo-HCT may be considered MEDICALLY NECESSARYas a treatment of 

• myelodysplastic syndromes or 
• myeloproliferative neoplasms 

in patients who are at high risk of intolerance of a myeloablative conditioning regimen. (see Policy Guidelines section).

Myeloablative allo-HCT or reduced-intensity conditioning allo-HCT for myelodysplastic syndromes and myeloproliferative neoplasms that does not meet the criteria in the Policy Guidelines section is investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

Policy Guidelines 
Myeloid Neoplasms
Myeloid neoplasms are categorized according to criteria developed by the World Health Organization (WHO). Neoplasms are risk-stratified using the International Prognostic Scoring System (IPSS).

2008 WHO Classification Scheme for Myeloid Neoplasms 

1. Acute myeloid leukemia (AML)

2. Myelodysplastic syndromes (MDS)

3. Myeloproliferative neoplasms (MPN)

   3.1 Chronic myelogenous leukemia

3.2 Polycythemia vera

  3.3 Essential thrombocythemia

 3.4 Primary myelofibrosis

 3.5 Chronic neutrophilic leukemia

 3.6 Chronic eosinophilic leukemia, not otherwise categorized

 3.7 Hypereosinophilic leukemia

 3.8 Mast cell disease

 3.9 MPNs, unclassifiable 

4. MDS/MPN 

4.1 Chronic myelomonocytic leukemia 

4.2 Juvenile myelomonocytic leukemia 

4.3 Atypical chronic myeloid leukemia 

4.4 MDS/MPN, unclassifiable 

5. Myeloid neoplasms associated with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1 

5.1 Myeloid neoplasms associate with PDGFRA rearrangement 

5.2 Myeloid neoplasms associate with PDGFRB rearrangement 

5.3 Myeloid neoplasms associate with FGFR1 rearrangement (8p11 myeloproliferative syndrome) 

2008 WHO Classification of Myelodysplastic Syndromes (MDS) 

1. Refractory anemia (RA) 
2. RA with ring sideroblasts 
3. Refractory cytopenia with multilineage dysplasia (RCMD) 
4. RCMD with ring sideroblasts 
5. RA with excess blasts 1 and 2 (RAEB 1 and 2) 
6. del 5q syndrome 
7. unclassified MDS 

Risk Stratification of MDS
Risk stratification for MDS is performed using the IPSS (see Table PG1). This system was developed after pooling data from 7 studies that used independent, risk-based prognostic factors. The prognostic model and the scoring system were based on blast count, degree of cytopenia, and blast percentage. Risk scores were weighted relative to their statistical power. This system is widely used to group patients into either low-risk and high-risk groups (see Table PG2). The low-risk group includes low-risk and intermediate-1 IPSS groups; treatment goals in low-risk MDS patients are to improve quality of life and achieve transfusion independence. In the high-risk group, which includes intermediate-2 and high-risk IPSS groups, treatment goals are slowing disease progression to AML and improving survival. IPSS is usually calculated on diagnosis. The role of lactate dehydrogenase, marrow fibrosis, and β₂-microglobulin also should be considered after establishing IPSS. If elevated, the prognostic category worsens by 1 category change.

Table PG1. IPSS: Myelodysplastic Syndrome Prognostic Variables

Variable	0	0.5	1.0	1.5	2.0
Marrow blasts, %	< 5	5 – 10	‒	11 – 20	21 – 30
Karyotype	Good	Intermediate	Poor
Cytopenias	0/1	2/3	‒	‒	‒

IPSS: International Prognostic Scoring System.

Table PG2. IPSS: Myelodysplastic Syndrome Clinical Outcomes 

Risk Group	Total Score	Median Survival, y	Time for 25% of Patients To Progress to AML
Low	0	5.7	9.4 years
Intermediate-1	0.5 – 1.0	3.5	3.3 years
Intermediate-2	1.5 – 2.0	1.2	1.12 years
High	³2.5	0.4	0.2 years

AML: acute myelocytic leukemia; IPSS: International Prognostic Scoring System.

An updated 5-category IPSS has been proposed for prognosis in patients with primary MDS or secondary AML to account for chromosomal abnormalities frequently seen in MDS (Schanz et al., 2012). This system stratifies patients into 5 categories: very poor, poor, intermediate, good, and very good. There has also been an investigation into using the 5-category IPSS to better characterize risk in MDS.

Given the long natural history of MDS, allogeneic hematopoietic cell transplantation (allo-HCT) is typically considered in patients with increasing numbers of blasts, signaling a possible transformation to AML. Subtypes falling into this category include refractory anemia with excess blasts, refractory anemia with excess blasts in transformation, or chronic myelomonocytic leukemia.

Patients with refractory anemia with or without ringed sideroblasts may be considered candidates for allo-HCT when chromosomal abnormalities are present, or when the disorder is associated with the development of significant cytopenias (e.g., neutrophils < 500/mm³, platelets <20,000/mm³).

Patients with MPN may be considered candidates for allo-HCT when there is a progression to myelofibrosis or toward acute leukemia. In addition, allo-HCT may be considered in patients with essential thrombocythemia with an associated thrombotic or hemorrhagic disorder. Use of allo-HCT should be based on the following criteria: cytopenias, transfusion dependence, increasing blast percentage over 5%, and age.

Some patients for whom a conventional myeloablative allo-HCT could be curative may be candidates for reduced-intensity conditioning allo-HCT. They include patients whose age (typically > 60 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy, low Karnofsky Performance Status) preclude the use of a standard myeloablative conditioning regimen. The ideal allogeneic donors are human leukocyte antigen (HLA)-identical siblings, matched at the HLA-A, -B, and -DR loci (6/6). Related donors mismatched at 1 locus are also considered suitable donors. A matched, unrelated donor identified through the National Marrow Donor Registry is typically the next option considered. Recently, there has been interest in haploidentical donors, typically a parent or a child of the patient, who usually share only 3 of the 6 major histocompatibility antigens. Most patients will have such a donor; however, the risk of graft-versus-host disease and overall morbidity of the procedure may be severe, and experience with these donors is not as graft-versus-host disease extensive as that with matched donors.

Evidence and clinical guidelines suggest reduced-intensity conditioning allo-HCT may be considered as a risk-adapted strategy for high-risk patients of MAC-intolerance as follows:

MDS 

• Older age
• IPSS intermediate-2 or high risk
• Multiple comorbidities (e.g., HSCT-comorbidity index (HCT-CI) score higher than 2)
• Red blood cell transfusion dependence
• Neutropenia
• Thrombocytopenia
• High-risk cytogenetics
• Increasing blast percentage

MPN 

• Cytopenias
• Transfusion dependence
• Increasing blast percentage over 5%
• Age 60 to 65 years.

Please see the Codes table for details.

Benefit Application
BlueCard/National Account Issues
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Rationale
Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance, and the quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice. The following is a summary of the key literature to date.

Myelodysplastic Syndromes
Clinical Context and Therapy Purpose
The purpose of myeloablative or reduced-intensity conditioning allogeneic (RIC) hematopoietic cell transplant (allo-HCT) in patients who have myelodysplastic syndrome (MDS) is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does myeloablative or RIC allo-HCT improve the net health outcome in patients with MDS?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with MDS.

Interventions
The therapies being considered are myeloablative or RIC allo-HCT.

Comparators
The following therapies are currently being used: standard of care.

Outcomes
The general outcomes of interest are mortality and morbidity. Beneficial outcomes are an improvement in overall survival (OS) and disease-specific survival. Harmful outcomes are treatment-related morbidity and mortality. Follow-up over months to years is of interest for relevant outcomes.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Myeloablative Conditioning Allogeneic Hematopoietic Cell Transplantation
Despite the successes seen with drugs now available to treat MDS (e.g., decitabine, azacitidine, lenalidomide), allo-HCT is the only treatment capable of complete and permanent eradication of the MDS clone.⁶

Systematic Review
A 2009 review of HCT for MDS evaluated the evidence for allo-HCT with myeloablative conditioning (MAC) for MDS.⁷ Reviewers selected 24 studies (prospective and retrospective) published between 2000 and 2008 that included a total 1,378 cases (age range, 32 to 59 years). Most patients (n = 885) received matched-related donor allo-HCT, with other donor types including syngeneic, matched, unrelated donor, mismatched unrelated donor, and umbilical cord blood. Most studies included de novo and secondary MDS, chronic myelomonocytic leukemia, myeloproliferative neoplasms, de novo and secondary acute myeloid leukemia (AML), and transformed AML. Peripheral blood and bone marrow stem cell grafts were allowed in most studies. The most commonly used conditioning regimens were busulfan plus cyclophosphamide (CY) and CY plus total body irradiation, with cyclosporine A used for graft-versus-host disease (GVHD) prophylaxis. Length of follow-up ranged from 5 months to approximately 8 years. Acute GVHD (grades II to IV) varied from 18% to 100%. Relapse risk ranged from 24% at 1 year to 36% at 5 years. The OS rates ranged from 25% at 2 years to 52% at 4 years, with nonrelapse mortality ranging from 19% at day 100 to 61% at 5 years.

A 2009 review from the American Society for Blood and Marrow Transplantation evaluated the evidence related to HCT in the therapy of MDS, with associated treatment recommendations.⁸ Reviewers concluded that outcomes improved with early HCT for patients with an International Prognostic Scoring System (IPSS) score of intermediate-2 or high-risk at diagnosis who had a suitable donor and met the transplant center’s eligibility criteria, and for selected patients with a low or intermediate-1 risk IPSS score at diagnosis who had a poor prognostic feature not included in the IPSS (i.e., older age, refractory cytopenias). Koenecke et al. (2015) evaluated the impact on the revised 5-category IPSS score (IPSS-5) on outcomes after HCT in patients with MDS or secondary AML (evolved from MDS).⁹ In a cohort of 903 patients retrospectively identified from the European Society for Blood and Marrow Transplantation database, those with poor and very poor risk had shorter relapse-free survival (RFS) and OS than those with very good, good, or intermediate risk. However, the ways that transplant management strategies should change based on cytogenetic abnormalities are not currently well defined.

Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation
Systematic Reviews
Song et al. (2021) evaluated the efficacy of RIC followed by allo-HCT in patients with AML and MDS via a meta-analysis of 6 RCTs (N = 1413).10, The 6 RCTs compared r RIC to MAC before first allo-HCT in patients with AML in complete remission or MDS, had a median follow-up of > 1 year, and displayed a low risk of bias. The primary endpoint was OS. Results revealed that OS was not significantly different between RIC and MAC (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.64 to 1.4; p = .80), with combined long-term follow-up data also showing no difference in OS between the 2 conditioning approaches (HR, 0.86; 95% CI, 0.53 to 1.41; p = .56). The cumulative incidence of relapse was also similar between the groups (HR, 1.18; 95% CI, 0.88 to 1.49; p = .28). Nonrelapse mortality was significantly improved with RIC as compared to total body irradiation/busulfan-based MAC (HR, 0.53; 95% CI, 0.36 to 0.8; p = .002); however, treosulfan-based MAC significantly reduced nonrelapse mortality as compared to RIC (HR, 1.67; 95% CI, 1.02 to 2.72; p = .04). RIC was associated with a trend of increasing graft failure (p = .06); however, graft failure in both arms was rare. The median duration of follow-up among the studies ranged from 12 to 119 months. The authors concluded that RIC is recommended as an adequate option of preparative treatment before allo-HCT for patients with AML in complete remission or MDS. Limitations of the meta-analysis included the small number of included clinical trials, significant heterogeneity between included studies for some outcomes, and lack of blinding in some studies.

Randomized Controlled Trials
No published randomized trials have compared RIC plus allo-HCT with conventional chemotherapy alone in patients with MDS and AML for whom MAC chemotherapy and allo-HCT are contraindicated.

Three RCTs, all of which are included in the systematic review by Song et al. (2021),¹⁰ have compared RIC and myeloablative regimens before allo-HCT in patients with MDS.^11,12,13 The RCTs are heterogeneous in patient characteristics and conditioning regimens and their findings vary based on these differences. In a long-term follow-up of one of the RCTs¹², Scott et al. (2021) found that, at 4 years, transplant-related mortality was significantly increased with MAC as compared to RIC (25.1% vs. 9.9%; p < .001) and those who received RIC had a significantly increased relapse risk (HR, 4.06; 95% CI, 2.59 to 6.35; p < .001).¹⁴ Among those who relapsed after HCT, postrelapse survival was similar between groups at 3 years (24% for MAC vs. 26% for RIC). Patients administered MAC had superior OS (HR, 1.54; 95% CI, 1.07 to 2.2; p = .03).

Overall, findings from these RCTs appear consistent with the American Society for Blood and Marrow Transplantation’s (2009) systematic review (previously described), which assessed the evidence supporting reduced-intensity and myeloablative conditioning regimens and drew the following conclusions: “There are insufficient data to make a recommendation for an optimal conditioning regimen intensity. A range of dose intensities is currently being investigated, and the optimal approach will likely depend on disease and patient characteristics, such as age and comorbidities.”⁸ Other reviews (2010 to 2012) have also drawn conclusions similar to those of the American Society for Blood and Marrow Transplantation.^{15,16,17,18,19,20} Given the absence of curative therapies for these patients, RIC allo-HCT may be considered as a risk-adapted treatment strategy for patients with MDS who could benefit from allo-HCT but who are at high risk of MAC regimen intolerance.

Noncomparative and Observational Studies
Additional nonrandomized evidence includes uncontrolled studies and prospective and retrospective cohort studies. Evidence from a number of largely heterogeneous, uncontrolled studies of r RIC with allo-HCT has shown long-term remission (i.e., > 4 years) can be achieved, often with reduced treatment-related morbidity and mortality, in patients with MDS or AML who otherwise would not be candidates for MAC regimens.^{7,21,22,23,24,25,26,27,28,29,30,31} These prospective and retrospective studies included cohorts of 16 to 215 patients similar to those in the MAC allo-HCT studies. The most common conditioning regimens used were fludarabine-based, with cyclosporine A and tacrolimus used for GVHD prophylaxis. The reported incidence of grades II to IV GVHD was 9% to 63%, with a relapse risk of 6% to 61%. Rates of OS ranged between 44% at 1 year and 46% at 5 years (median follow-up range, 14 months to > 4 years).

In general, nonrandomized studies of RIC compared to MAC showed a low rate of engraftment failure and low non-relapse mortality with RIC, but a higher relapse rate than with MAC allo-HCT. Zeng et al. (2014) conducted a systematic review and meta-analysis comparing outcomes for patients who had MDS or AML treated with HCT plus reduced-intensity or myeloablative conditioning.³² Reviewers included 8 studies (2 prospective, 8 retrospective), with a total of 6,464 AML or MDS patients. Of these, 171 received RIC and 4893 received MAC. Overall, r RIC treated patients were older and more likely to have multiple comorbidities. In the pooled analysis, OS, RFS, and nonrelapse mortality did not differ significantly between patients receiving reduced-intensity and myeloablative conditioning. Relapse incidence was significantly lower in the MAC arm (odds ratio [OR] for RIC vs. MAC, 1.41; 95% CI, 1.24 to 1.59; p < .001).

Aoki et al. (2015) compared RIC with MAC in a retrospective cohort of 448 patients (age range, 50 to 69 years) with advanced MDS (refractory anemia with excess blasts or refractory anemia in transformation).³³ Of the total, 197 (44%) and 251 (56%) received myeloablative or r RIC, respectively. The groups differed at baseline: patients who received r RIC were significantly more likely to be 60 to 69 years old (vs. 50 to 59 years; 47% for RICvs. 47% for MAC; p = .001), and less likely to receive an unrelated donor transplant (54% vs. 70%; p = .001). Three-year OS rates did not differ between groups (44.1% for RIC vs. 42.7% for MAC; p = .330). Although patients treated with RIC had a significantly lower 3-year cumulative incidence of nonrelapse mortality (25.6% vs. 37.9%; p = .002), they had a significantly higher 3-year incidence of relapse th n patients treated with MAC (29.9% vs. 22.8%; p = .029).

Kim et al. (2012) published a phase 3 randomized trial (N=83 patients) comparing toxicity rates for 2 conditioning regimens (reduced CY, fludarabine, and anti-thymocyte globulin; standard CY anti-thymocyte globulin).34, Four patients had MDS, and the remaining patients had severe aplastic anemia. Overall, the incidence of reported toxicities was lower in patients receiving the RIC regimen (23% vs. 55%; p=.003). Subgroup analyses showed no differences in the overall results based on differential diagnosis.

Outcomes After Allogeneic Hematopoietic Cell Transplantation in Mixed Myelodysplastic Syndrome Populations
Noncomparative and Observational Studies
A number of studies, primarily retrospective, continue to report outcomes from allo-HCT for MDS in a variety of patient populations and to evaluate the impact of specific patient, conditioning, and donor characteristics on outcomes; representative studies are summarized in Table 1.

Table 1. Case Series of Hematopoietic Cell Transplantation Treatment for Myelodysplastic Syndrome

Study	Patient Population	Type of HCT	Summary of Outcomes
Basquiera et al. (2015)35	52 pediatric patients with MDS	Allo-HCT (59% with related donors) Stem cell source: Bone marrow, 63% Peripheral blood, 26% Umbilical cord blood, 11%	5-y DFS = 50% 5-y OS = 55%
Boehm et al.  (2014)36	60 adults with MDS or secondary AML	Allo-HCT MAC in 36 patients; RIC in 24 patients	10-y OS = 46%
Damaj et al. (2014)37	128 adults with MDS: 40 received AZA before HCT and 88 received BSC	RIC allo-HCT	3-y OS = 53% in AZA group vs. 53% in BSC group (p = .69) 3-y RFS = 37% in AZA group vs. 42% in BSC group (p = .78) 3-y NRM = 20% in AZA group vs. 23% in BSC group (p = .74)
Di Stasi et al. (2014)38	227 patients with MDS or AML	Allo-HCT Donor source: Matched-related, 38% Matched-unrelated, 48% Haploidentical, 14%	3-y PFS for patients in remission: 57% for matched-related 45% for matched-unrelated 41% for haploidentical (p = .417)
Onida et al. (2014)39	523 patients with MDS IPSS cytogenic risk group: Good risk: 53.5% Intermediate risk: 24.5% Poor risk: 22%	Allo-HCT RIC in 12%	5-y OS based on IPSS cytogenic risk group: Good: 48% Intermediate: 45% Poor: 30%
Oran et al. (2014)40	256 patients with MDS Pretreatment: No cytoreductive chemo: 30.5% Chemo: 15.6% HMA: 47.7% Chemo + HMA: 6.2%	Allo-HCT RIC in 36.7%	3-y EFS based on cytoreductive therapy: No cytoreductive chemo: 44.2% Chemo: 30.6% HMA: 34.2% Chemo + HMA: 32.8% (p = .50)
Yoshimi et al. (2014)41	17 children with secondary MDS or AML after childhood aplastic anemia	Allo-HCT	5-y OS and EFS = 41%
Basquiera et al. (2016)42	84 adults with MDS Cytogenic risk group: Standard: 65.5% Adverse: 12.6% Unknown: 21.9%	Allo-HCT RIC in 31.1%	OS: Median: 23.5 mo (95% CI, 1.7 to 45.3 mo) 1-y = 61% (95% CI, 50% to 70%) 4-y = 38% (95% CI, 27% to 49%) PFS: Median: 19.9 mo (95% CI, 9 to 31 mo) 1-y = 57% (95% CI, 46% to 67%) 4-y = 37% (95% CI, 26% to 48%)
Symeonidis et al. (2015)43	513 adults with CMML Pretreatment: No prior disease-modifying therapy: 28% Disease-modifying therapy: 72%	Allo-HCT RIC in 41.6%	1-y NRM = 31% 4-y NRM = 41% 4-y RFS = 27% 4-y OS = 33%
Pohlen et al. (2016)44	187 patients with refractory AML (87%) or high-risk MDS (13%)	Allo-HCT RIC in 52% Unrelated donors in 73% Stem cell source: Bone marrow, 6% Peripheral blood, 94%	3-y RFS = 32% (95% CI, 25% to 39%) 3-y OS = 35% (95% CI, 27% to 42%)
Heidenreich et al. (2017)45	313 adults with MDS and secondary AML, age ≥ 70 Cytogenic risk group: Good: 51% Intermediate: 22% Poor/very poor: 11%	Allo-HCT RIC or non-MAC in 83% Unrelated donors in 75% Stem cell source: Bone marrow, 6% Peripheral blood, 94%	1-y NRM: 32% 3-y relapse: 28% 3-y OS: 34%

allo; allogeneic; AML: acute myelogenous leukemia; AZA: azacitidine; BSC: best supportive care; chemo: chemotherapy; CI: confidence interval; CMML: chronic myelomonocytic leukemia; DFS: disease-free survival; EFS: event-free survival; HMA: hypomethylating agents; HCT: hematopoietic cell transplantation; IPSS: International Prognostic Scoring System; MAC: myeloablative conditioning; MDS: myelodysplastic syndromes; NRM: nonrelapse mortality; OS: overall survival; PFS: progression-free survival; RFS: relapse-free survival; RIC: reduced-intensity conditioning.

Section Summary: Myelodysplastic Syndrome
Primarily uncontrolled, observational studies of HCT for MDS have reported a relatively large range of OS and progression-free survival values, which reflect the heterogeneity in patient populations, conditioning regimens, and other factors. Reported estimates for 3- to 5-year OS of 40% to 50% are typical. Evidence from randomized and nonrandomized comparisons has suggested that RICmay be used as a risk-adapted strategy in high-risk patients who are older and with more comorbidities without significantly worsening OS. RIC appears to be associated with lower rates of nonrelapse mortality but higher cancer relapse than MAC HCT.

Myeloproliferative Neoplasms
Clinical Context and Therapy Purpose
The purpose of MAC and RIC allo-HCT in patients who have myeloproliferative neoplasms is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does MAC or RIC allo-HCT improve the net health outcome in patients who have myeloproliferative neoplasms?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals who have myeloproliferative neoplasms.

Interventions
The therapies being considered are MAC or RIC allo-HCT.

Comparators
The following therapies are currently being used: standard of care.

Outcomes
The general outcomes of interest are mortality and morbidity. Beneficial outcomes are an improvement in OS and disease-specific survival. Harmful outcomes are treatment-related morbidity and mortality. Follow-up over months to years is of interest for relevant outcomes.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Data on therapy for myeloproliferative neoplasms are sparse.^28,46,47 As outlined in this evidence review, with the exception of MAC chemotherapy and allo-HCT, no therapy has yet proven to be curative or to prolong survival of patients with myeloproliferative neoplasms.

Systematic Reviews
Bewersdorf et al. (2021) assessed the available evidence on the efficacy and safety of allo-HCT in patients with myelofibrosis in a systematic review involving 43 studies (N = 8,739).⁴⁸ The analysis included 38 retrospective, 1 prospective, and 4 phase II clinical trials. Conditioning regimens used were variable with only 3 and 14 studies using exclusively MAC or RIC regimens, respectively. Additionally, donor sources and pre-transplantation treatment histories differed considerably among studies. The co-primary outcome was 1-, 2-, and 5-year OS. Rates of nonrelapse mortality, RFS or progression-free survival (PFS), and safety were also evaluated. Regarding survival, 1-year, 2-year, and 5-year OS rates were 66.7% (95% CI, 63.5% to 69.8%), 64.4% (95% CI, 57.6% to 70.6%), and 55% (95% CI, 51.8% to 58.3%), respectively. Nonrelapse mortality rates for the same time periods were 25.9% (95% CI, 23.3% to 28.7%), 29.7% (95% CI, 24.5% to 35.4%), and 30.5% (95% CI, 25.9% to 35.5%). Rates of 1-, 2- and 5-year RFS were 65.3% (95% CI, 56.5% to 73.1%), 56.2% (95% CI, 41.6% to 69.8%), and 53.6% (95% CI, 39.9% to 66.9%), respectively. PFS rates were 56.9% (95% CI, 41.4% to 71.2%), 50.6% (95% CI, 39.7% to 61.4%), and 43.5% (95% CI, 31.9% to 55.8%) for these same time periods. Acute GVHD was reported in 44% of patients, with chronic GVHD occurring in 46.5% of patients. The combined rate of graft failure was 10.6% (95% CI, 8.9% to 12.5%). Overall, the quality of the evidence was limited by the absence of RCTs and the retrospective design of most studies. Additionally, patient and transplant characteristics were variable among the included studies leading to moderate to substantial heterogeneity in the analyses.

Noncomparative and Observational Studies
The largest study identified evaluating allo-HCT for primary myelofibrosis comes from a 2010 analysis of the outcomes for 289 patients treated between 1989 and 2002, from the database of the Center for International Bone Marrow Transplant Research.⁴⁹ Median age was 47 years (range, 18 to 73 years). Donors were human leukocyte antigen (HLA)-identical siblings in 162 patients, unrelated individuals in 101 patients, and HLA nonidentical family members in 26 patients. Patients were treated with a variety of conditioning regimens and GVHD prophylaxis regimens. Splenectomy was performed in 65 patients before transplantation. The 100-day treatment-related mortality was 18% for HLA-identical sibling transplants, 35% for unrelated transplants, and 19% for transplants from alternative-related donors. Corresponding 5-year OS rates were 37%, 30%, and 40%, respectively. Disease-free survival (DFS) rates were 33%, 27%, and 22%, respectively. Rates of DFS for patients receiving reduced-intensity conditioning allo-HCT were comparable: 39% for HLA-identical sibling donors and 17% for unrelated donors at 3 years. In this large retrospective series, allogeneic transplantation for myelofibrosis resulted in long-term RFS in about one-third of patients.

The significant toxicity of MAC plus allo-HCT in myeloproliferative neoplasms has led to study of r RIC regimens for these diseases. Data from a direct, prospective comparison of outcomes of MAC and allo-HCT versus RIC and allogeneic stem cell support in myeloproliferative neoplasms are not available, but single-arm series and nonrandomized comparative studies have reported outcomes after RIC allo-HCT. One 2008 series included 27 patients (mean age, 59 years) with myeloproliferative neoplasms who underwent allo-HCT using a r RIC regimen of low-dose (2 gray) total body irradiation alone with or without fludarabine.²⁶ At a median follow-up of 47 months, 3-year RFS was 37%, 3-year OS was 43%, and 3-year nonrelapse mortality was 32%.

A 2009 retrospective study analyzed the impact of conditioning intensity on outcomes for allo-HCT in patients with myelofibrosis.⁵⁰ This multicenter trial included 46 consecutive patients treated at 3 Canadian and 4 European transplant centers between 1998 and 2005. Twenty-three patients (median age, 47 years; range, 31 to 60 years) underwent MAC and 23 patients (median age, 54 years; range, 38 to 74 years) underwent RIC. The majority in both groups (85%) were deemed intermediate- or high-risk. At a median follow-up of 50 months (range, 20 to 89 months), there was a trend for a better PFS rate at 3 years in RIC patients than in MAC patients (58% [range, 23% to 62%] vs. 43% [range, 35% to 76%], respectively; p = .11); there was a similar trend in the 3-year OS rate (68% [range, 45% to 84%] vs. 48% [range, 27% to 66%], respectively; p = .08). Nonrelapse mortality rates at 3 years trended higher in MAC cases (48%; range, 31% to 74%) than in r RIC cases (27%; range, 14% to 55%; p = .08). The results of this study suggested that both types of conditioning regimens have curative potential in patients with myelofibrosis. Despite the RIC patients being significantly older, with longer disease duration and poorer performance status than those who received conventional conditioning, the groups had similar outcomes, supporting the use of RIC allo-HCT in this population.

Section Summary: Myeloproliferative Neoplasms
Observational studies of HCT for myeloproliferative neoplasms have reported a range of 3- to 5-year OS rates from 35% to 50% and suggested that HCT may be associated with improved survival in patients with intermediate-2 and high-risk disease. Primarily, retrospective studies have compared the RIC and MAC regimens. While these nonrandomized comparisons have suggested that reduced-intensity conditioning may be used in patients who are older and who have poorer performance status without significantly worsening OS, randomized trials are needed to provide greater certainty in the efficacy of the conditioning regimens.

Summary of Evidence
For individuals who have MDS who receive MAC or RIC allo-HCT, the evidence includes systemic reviews, RCTs, and numerous case series, which are often heterogeneous in terms of diseases included. Relevant outcomes are OS, disease-specific survival, and treatment-related mortality and morbidity. Primarily uncontrolled, observational studies of HCT for MDS have reported a relatively large range of overall and PFS rates, which reflect the heterogeneity in patient populations, conditioning regimens, and other factors. Reported estimates for 3- to 5-year OS of 40% to 50% are typical. Evidence from randomized and nonrandomized comparisons has suggested that RIC may be used as a risk-adapted strategy in high-risk patients who are older and with more comorbidities without significantly worsening OS. RIC appears to be associated with lower rates of nonrelapse mortality but higher cancer relapse than MAC HCT. At present, HCT is the only potentially curative treatment option for patients with MDS. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have myeloproliferative neoplasms who receive MAC or RIC allo- HCT, the evidence includes a systematic review and retrospective observational series. Relevant outcomes are OS, disease-specific survival, and treatment-related mortality and morbidity. Evidence has suggested that RIC may be used as a risk-adapted strategy in high-risk patients who are older and have more comorbidities without significantly worsening OS. RIC appears to be associated with lower rates of nonrelapse mortality but higher cancer relapse than myeloablative HCT. At present, HCT is the only potentially curative treatment option for patients with myeloproliferative neoplasms. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in Supplemental Information if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

National Comprehensive Cancer Network
Current National Comprehensive Cancer Network clinical guidelines for myelodysplastic syndromes (v. 2.2022) make the following general recommendation about allogeneic hematopoietic cell transplanatation (allo-HCT):⁵¹

“For patients who are transplant candidates, an HLA [human leukocyte antigen]-matched sibling, or HLA-matched unrelated donor can be considered. Results with HLA-matched unrelated donors have improved to levels comparable to those obtained with HLA-matched siblings. With the increasing use of cord blood or HLA-haploidentical related donors, HCT has become a viable option for many patients. High-dose conditioning is typically used for younger patients, whereas RIC [reduced-intensity conditioning] for HCT is generally the strategy in older individuals.”

Specific National Comprehensive Cancer Network recommendations for HCT for treatment of myelodysplastic syndromes are outlined in Table 2.⁵¹

Table 2. Guidelines for Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes

Prognostic Category	Recommendations for Allo-HCT
IPSS low/intermediate-1 OR IPSS-R very low, low, intermediate OR WPSS very low, low, intermediate	Consider allo-HCT for select patients who have clinically relevant thrombocytopenia or neutropenia or increased marrow blasts, with disease progression or no response after azacitidine/decitabine or immunosuppressive therapy Consider allo-HCT for patients who have symptomatic anemia with no 5q deletion, with serum erythropoietin level > 500 mU/mL, with poor probability of response to immunosuppressive therapy, and no response or intolerance to azacitidine/decitabine or immunosuppressive therapy
IPSS intermediate-2, high OR IPSS-R intermediate, high, very high OR WPSS high, very high	Recommend allo-HCT if a high-intensity therapy candidate and transplant candidate and donor stem cell source is available

allo: allogeneic; HCT: hematopoietic cell transplantation; IPSS: International Prognostic Scoring System; WPSS: WHO Classification-based Prognostic Scoring System.
Table 3 summarizes the National Comprehensive Cancer Network recommendations (v. 2.2021) on the use of allo-HCT for the treatment of myeloproliferative neoplasms.52, The guidelines note that selection of allo-HCT should be based on age, performance status, major comorbid conditions, psychosocial status, patient preference, and availability of caregiver.

Table 3. Guidelines for Allogeneic Hematopoietic Cell Transplantation for Myeloproliferative Neoplasms

Prognostic Category	Recommendations for Allo-HCT
Intermediate risk - 1 myelofibrosis IPSS = 1 DIPSS-Plus = 1 DIPSS = 1 or 2	Consider observation or ruxolitinib, peginterferon alfa-2a, or hydroxyurea if symptomatic (useful in certain circumstances) or allo-HCT Evaluation for allo-HCT is recommended for patients with low platelet counts or complex cytogenetics
Intermediate risk - 2 myelofibrosis IPSS=2 DIPSS-Plus = 2 or 3 DIPSS = 3 or 4 High-risk myelofibrosis IPSS > 3 DIPSS-Plus = 4 to 6 DIPSS = 5 or 6	Consider allo-HCT immediately or bridging therapy can be used to decrease marrow blasts to an acceptable level prior to transplant Evaluation for allo-HCT is recommended for all patients
Disease progression to advanced-stage/AML	Induce remission with hypomethylating agents ± JAK inhibitors or intensive induction chemotherapy followed by allo-HCT

allo: allogeneic; AML: acute myeloid leukemia; DIPSS: Dynamic International Prognostic Scoring System; HCT: hematopoietic cell transplantation; IPSS: International Prognostic Scoring System; JAK: Janus kinase.

American Society of Transplantation and Cellular Therapy
In 2020, the American Society of Transplantation and Cellular Therapy (formerly The American Society for Blood and Marrow Transplantation) published updated guidelines on indications for HCT and immune effector cell therapy based on the recommendations of a multiple-stakeholder task force.⁵³ Table 4 summarizes categorizations for allo-HCT in adults.

Table 4. Recommendations for the Use of Hematopoietic Cell Transplantation to Treat Myelodysplastic Syndromes, Myelofibrosis, and Myeloproliferative Neoplasms

Indication	Recommendation
Myelodysplastic syndromes
Low/intermediate-1 risk	Standard of care, clinical evidence available (large clinical trials and observational studies are not available; however, sufficiently large cohort studies have shown efficacy with “acceptable risk of morbidity and mortality”)
Intermediate-2/high-risk	Standard of care (“well defined and generally supported by evidence in the form of high-quality clinical trials and/or observational studies”)
Myelofibrosis and myeloproliferative neoplasms
Primary, low-risk	Standard of care (“well defined and generally supported by evidence in the form of high-quality clinical trials and/or observational studies”)
Primary, intermediate/high-risk	Standard of care (“well defined and generally supported by evidence in the form of high-quality clinical trials and/or observational studies”)
Secondary	Standard of care (“well defined and generally supported by evidence in the form of high-quality clinical trials and/or observational studies”)
Hypereosinophilic syndromes, refractory	Standard of care, rare indication (clinical trials and observational studies are not feasible due to low incidence; small cohorts have shown efficacy with “acceptable risk of morbidity and mortality”)

U.S. Preventive Services Task Force Recommendations
Not applicable

Ongoing and Unpublished Clinical Trials
Some currently ongoing trials that might influence this review are listed in Table 5.

Table 5. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT00739141	Conditioning Regimen and the Transplantation of Unrelated Donor Umbilical Cord Blood in Patients with Hematologic Malignancies	86	Oct 2021
NCT01760655	Reduced Intensity Conditioning Before Donor Stem Cell Transplant in Treating Patients with High-Risk Hematologic Malignancies	72	Sep 2022
NCT02757989	Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Myelodysplastic Syndrome Low Risk	79	Jun 2024

NCT: national clinical trial.

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48. Bewersdorf JP, Sheth AH, Vetsa S, et al. Outcomes of Allogeneic Hematopoietic Cell Transplantation in Patients With Myelofibrosis-A Systematic Review and Meta-Analysis. Transplant Cell Ther. Oct 2021; 27(10): 873.e1-873.e13. PMID 34052505
49. Ballen KK, Shrestha S, Sobocinski KA, et al. Outcome of transplantation for myelofibrosis. Biol Blood Marrow Transplant. Mar 2010; 16(3): 358-67. PMID 19879949
50. Gupta V, Kroger N, Aschan J, et al. A retrospective comparison of conventional intensity conditioning and reduced-intensity conditioning for allogeneic hematopoietic cell transplantation in myelofibrosis. Bone Marrow Transplant. Sep 2009; 44(5): 317-20. PMID 19234505
51. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Myelodysplastic Syndromes, Version 1.2022. https://www.nccn.org/professionals/physician_gls/pdf/mds.pdf. Accessed November 13, 2021.
52. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Myeloproliferative Neoplasms, Version 2.2021. https://www.nccn.org/professionals/physician_gls/pdf/mpn.pdf. Accessed November 14, 2021.
53. Kanate AS, Majhail NS, Savani BN, et al. Indications for Hematopoietic Cell Transplantation and Immune Effector Cell Therapy: Guidelines from the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant. Jul 2020; 26(7): 1247-1256. PMID 32165328
54. Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Stem Cell Transplantation Formerly 110.8.1 (110.23). 2016; https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=366 Accessed November 13, 2021.

Coding Request  

Codes	Number	Description
CPT	38204	Management of recipient hematopoietic cell donor search and cell acquisition
	38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection, allogeneic
	38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
	38209	; thawing of previously frozen harvest with washing, per donor
	38210	; specific cell depletion with harvest, T cell depletion
	38211	; tumor cell depletion
	38212	; red blood cell removal
	38213	; platelet depletion
	38214	plasma (volume) depletion
	38215	; cell concentration in plasma, mononuclear, or buffy coat layer
	38230	Bone marrow harvesting for transplantation, allogeneic
	38240	Bone marrow or blood-derived peripheral stem-cell transplantation: allogeneic
	86812-86822	Histocompatibility studies code range (eg, for allogeneic transplant)
ICD-9 Procedure	41.02	Allogeneic bone marrow transplant with purging
	41.03	Allogeneic bone marrow transplant without purging
	41.05	Allogeneic hematopoietic stem-cell transplant without purging
	41.08	Allogeneic hematopoietic stem-cell transplant with purging
	41.91	Aspiration of bone marrow from donor for transplant
	99.79	Other therapeutic apheresis (includes harvest of stem cells)
ICD-9 Diagnosis	238.72-238.79	Myelofibrosis or myelodysplastic syndrome, code range (myeloproliferative syndrome is included in 238.79)
HCPCS	S2150	Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, highdose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)
ICD-10-CM (effective 10/01/15)	C92.10-C92.12	Chronic myeloid leukemia, BCR/ABL-positive code range
	C92.20-C92.22	Atypical chronic myeloid leukemia, BCR/ABL-negative code range
	C94.6	Myelodysplastic disease, not classified/Myeloproliferative disease, not classified
	D45	Polycythemia vera
	D46.0-D46.9	Myelodysplastic syndromes code range
	D47.0-D47.9	Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue code range
ICD-10-PCS (effective 10/01/15)		ICD-10-PCS codes are only used for inpatient services.
	30243G1, 30243X1, 30243Y1	Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list
	07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ	Surgical, lymphatic and hemic systems, extraction, bone marrow, code list
Type of Service	Therapy
Place of Service	Inpatient/Outpatient

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward     

07/07/2022	Annual review, no change to policy intent. Updating rationale and references.
07/15/2021	Annual review, no change to policy intent. Updating rationale and references.
07/23/2020	Annual review, no change to policy intent. Policy updated for clarity. Updating guidelines, rationale and references.
07/01/2019	Annual review, no change to policy intent. Updating background, rationale and references.
07/18/2018	Annual review, no change to policy intent. Updating description, background, rationale and references.
08/01/2017	Annual review, no change to policy intent. Updating title, background, description, rationale and references. Policy and guidelines being updated to utilize NCCN terminology, hematopoietic stem cell transplantation changed to hematopoietic cell transplantation.
07/19/2016	Annual review, no change to policy intent. Updating background, description, rationale and references. Adding benefit application and regulatory status.
08/03/2015	Annual review, no change to policy intent, however, for clarity, the following was added to the policy veribiage "Myeloablative allogeneic HSCT or reduced-intensity conditioning allogeneic-HSCT for myelodysplastic syndromes and myeloproliferative neoplasms that does not meet the criteria in the Policy Guidelines section is considered INVESTIGATIONAL.". Updated background, description, rationale and references. Added related policies and coding.
07/09/2014	Annual review. Updated description/background, rationale and references. No change to policy intent.