Certificate of Medical Necessity
Bone Marrow/Stem Cell Transplants
Please forward the completed CMN forms and other required documentation (i.e., letter of medical necessity from physician, patient history of
illness, all pertinent laboratory findings, diagnostic testing including radiology reports, and other pertinent documentation) to:
Fax: 904-357-6331
Email: CentralizedTransplantUnit@bcbsfl.com
Phone: 1-800-955-5692 x84157
SECTION A
Patient Name:
Patient Address:
City:
State:
Zip Code:
Patient
Fl
DOB:
Gender:
Patient BCBSF ID #
Physician’s Name
Physician’s NPI No.
Physician’s Address:
City:
State:
Zip Code:
Physician Phone:
Transplant Facility Name:
Provider Number:
Phone:
Fax:
NPI No.
Transplant Coordinator Name:
Phone:
Other:
Fax:
Financial Coordinator Name:
Phone:
Fax:
Referring Physician Name
ICD-9 Codes
Diagnosis Codes Description
(include co morbidity):
Caregiver/Support Person Contact:
Phone:
Relationship:
Urgent Request:
Currently Inpatient:
Fl
(###) ###-####
(###) ###-####
(###) ###-####
(###) ###-####
(###) ###-####
(###) ###-####
(###) ###-####
(###) ###-####
Yes
Yes
No
No
SECTION B – MUST BE COMPLETED
Please answer ALL of the following questions:
Check
Response
1. General Information:
A.
Type of Stem Cell Transplant?
B.
Specify: Autologous
C.
Is this a tandem request?
Allogeneic
Yes
No
If yes what #:
D.
Stem Cell Source: Bone Marrow
Peripheral Blood
Umbilical Cord Blood
2. Current Medical Information:
Were there any previous stem cell transplants?
If yes, please indicate type: Autologous
Did any previous stem cell transplant fail?
If yes, please indicate type: Autologous
Revised 09/15/13
Yes
No
Yes
No
Allogeneic
Allogeneic
Date:
Page 1 of 4
Created: 08/31/10
Is the diagnosis in accordance with Chapter 59-B of the Florida Administrative Code, allogeneic hematopoietic bone marrow
transplantation for one of the following (excluding Florida Blue Federal Employee Plan members)?

Chronic myelogenous leukemia

Acute myelogenous leukemia

Acute lymphoblastic leukemia

Chronic lymphocytic leukemia

Non-Hodgkin’s lymphoma

Myelodysplastic syndrome

Myeloid sarcoma

Hodgkin’s disease relapsed after autologous transplant, but not progressing on salvage therapy

Severe or very severe aplastic anemia, from HLA-compatible siblings for individuals below 40 years of age

Severe aplastic anemia unresponsive to immunosuppression

Hodgkin’s disease to treat primary refractory or relapsed disease

Multiple myeloma for:
Yes
No
Yes
No
Yes
No
o
Newly diagnosed disease
Treatment following initial round of autologous hematopoietic stem-cell transplantation
Treatment following primary graft failure or failure to engraft
o

Is the allogeneic hematopoietic , bone marrow transplantation for one of the following indications, to be performed in the context
of a well designed and conducted Phase II or Phase III clinical treatment trial?

Multiple myeloma and other plasma cell dyscrasias (e.g., Waldenstrom’s, amyloidosis)

Renal cell carcinoma

Hodgkin’s disease

Sickle cell anemia, thalassemia and other severe red cell disorders
Is allogeneic bone marrow transplantation being requested for one of the following indications?

Absent or defective natural killer function (eg, Chediak-Higashi syndrome)

Absent or defective neutrophil function (eg, Kostmann syndrome, chronic granulomatous disease, leukocyte
adhesion defect)

Aplastic anemia (including hereditary forms, such as Fanconi anemia, dyskeratosis congenital, ShwachmanDiamond, Diamond Blackfan, and acquired anemia (eg, secondary to drug or toxin exposure)

Wiskott-Aldrich syndrome

Severe combined immunodeficiency (SCID)

Sickle cell with either a history of prior stroke or at increased risk of stroke or end-organ damage

Homozygous beta-thalassemia (eg, thalassemia major)

Infantile malignant osteopetrosis (Albers-Schonberg disease or marble bone disease)

Inherited metabolic disease (eg, lysosomal and peroxisomal storage disorders)

Mucoplysaccharidoses in patients who are neurologically intact

Mucolipidoses for patients who have failed conventional therapy and are neurologically intact

Kostmann’s syndrome

Leukocyte adhesion deficiencies

X-linked lymphoproliferative syndrome

Recurrent or refractory medulloblastoma and other primitive neuroectodermal tumors (PNETS)

Recurrent or refractory Ewing’s sarcoma
Revised 12/15/14
Page 2 of 4
Created: 08/31/10
Is the diagnosis in accordance with Chapter 59-B of the Florida Administrative Code, autologous bone marrow transplantation for
one of the following (excluding Florida Blue Federal Employee Plan members)?

Acute myelogenous leukemia

Hodgkin’s disease

Non-Hodgkin’s lymphoma

Ewing’s sarcoma, chemotherapy sensitive after first relapse

Neuroblastoma

Germ cell tumor, after failure of first therapy but not progressing on salvage therapy

Multiple myeloma (including double bone marrow transplant)

Primary amyloidosis

PNET (including medulloblastoma and pinealoblastoma) chemotherapy sensitive after first relapse

Medulloblastoma and other PNET tumors, metastatic, at diagnosis

Severe aplastic anemia unresponsive to immunosuppression
Is the autologous bone marrow transplantation for one of the following indications, to be performed in the context of a well
designed and conducted Phase II or Phase III clinical treatment trial?

Chronic lymphocytic leukemia

Plasma cell dyscrasias other than multiple myeloma (e.g., Waldenstrom’s)

Breast cancer

Ewing’s sarcoma, localized, greater than 8 cm or metastatic at presentation

Soft tissue sarcoma, pediatric, after failure of first therapy

Wilm’s tumor, at relapse

Germ cell tumor, high risk, at diagnosis

Multiple autologous bone marrow transplants for pediatric solid tumors

Metastatic malignant melanoma

Embryonic tumors of the central nervous system to treat recurrence or as consolidation therapy for previously
Yes
No
Yes
No
Yes
No
Yes
No
untreated tumors that show partial or complete response to induction chemotherapy, or stable disease

Testicular tumors as salvage therapy or platinum refractory disease

Ewings sarcoma as initial treatment of high-risk Ewings sarcoma or recurrent or refractory disease

Germ cell tumor with favorable prognostic factors that failed a previous course of conventional-dose salvage
therapy

Germ cell tumor as initial treatment of first relapse in member with unfavorable prognostic factors or for platinum-
refractory disease
Is the bone marrow transplantation for one of the following rare diseases, in accordance with Chapter 59-B of the Florida
Administrative Code, to be performed at a Blood and Marrow Transplant Clinical Trials Network (BMT CNT) core or non-core
facility?

Myelofibrosis

Chronic myelomonocytic leukemia (CMML)

Paroxysmal nocturnal hemoglobinuria (PNH)

POEMS syndrome
For a bone marrow transplant outside of a clinical trial are the following criteria met?

The plan of care follows a clinical trial protocol that meets the requirements the note section below

Member cannot be enrolled in the proposed clinical trial

Bone marrow transplant treatment is medically necessary

Treatment Center is part of the Blood and Marrow Transplant Clinical Trials Network

Member is appropriate candidate for bone marrow transplant
Note: A well-designed and conducted clinical treatment trial is one which includes an IRB-approved written protocol. At a minimum,
such protocol shall have specific criteria for evaluating the effect of treatment with defined endpoints that are precise, meaningful,
and reliable and which allow valid conclusions to be drawn about therapeutic efficacy and safety. Protocols should include an
adequate statistical section describing the method of randomization and stratification, if any, expected outcome parameters
relating to response rates, time to progression, survival times and other relevant information. Such clinical treatment trials shall be
consistent with protocols reviewed and approved by the National Cancer Institute for scientific merit.
Revised 09/15/13
Page 3 of 4
Created: 08/31/10
Is a reduced-intensity allogeneic hematopoietic stem cell transplantation for a member who would otherwise meet
Yes
No
Is reduced-intensity allogeneic hematopoietic stem cell transplantation for the following indications when the bone
marrow transplantation procedure is performed in the context of a well-designed and conducted Phase II or Phase
III clinical treatment trial?
 Multiple myeloma and other plasma cell dyscrasias (e.g., Waldenstrom’s, amyloidosis)
 Renal cell carcinoma
 Hodgkin’s disease
 Sickle cell anemia, thalassemia and other severe red cell disorders
Yes
No
Is reduced-intensity allogeneic hematopoietic stem cell transplantation for the following indications?
Yes
No
selection criteria for high-dose chemotherapy and allogeneic stem cell transplantation for the following indications?
 Acute myelogenous leukemia
 Chronic myelogenous leukemia
 Acute lymphoblastic leukemia
 Chronic lymphoblastic leukemia
 Non-Hodgkin’s lymphoma
 Myelodysplastic syndrome
 Myeloproliferative neoplasms
Hodgkin’s disease
 To treat primary refractory or relapsed disease
 To treat member who has failed a prior autologous HSCT used to treat primary refractory or
relapsed disease
 To treat member who would otherwise qualify for a myeloablative allogeneic transplant, but
would be unable to tolerate a standard myeloablative conditioning regimen
 When insufficient stem cells are collected for an autologous HSCT.
Multiple myeloma
 To treat newly diagnosed multiple myeloma following an initial round of autologous
hematopoietic stem-cell transplantation
 To treat multiple myeloma with primary graft failure or failure to engraft
Form completed by:
Name/Title (Printed):
Signature:
______________________________________________________
Date:
Please complete all parts as clearly and as specifically as possible. Omissions, generalities and illegibility will result in the
form being returned for completion or clarification. All supporting documentation should be sent with this form.
Revised 12/15/14
Page 4 of 4
Created: 08/31/10