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In the hiatus following the cancellation of family contracts last autumn two new family fee schemes, due for implementation, were postponed. The Legal Services Commission (LSC) has now announced their belated introduction from 9 May. The new schemes are:
The Family Advocacy Scheme. Under this scheme both solicitor advocates and barristers claim a single, graduated fee for advocacy work done on public and private family law cases.
The Private Family Law Representation Scheme. Under this scheme solicitors claim a standard fixed fee for work done (excluding advocacy) from the issue of proceedings to the conclusion of the final hearing.
The LSC say that online training to help preparation for the new family fee schemes is now available on their training website and encourage family providers and advocates affected by the new schemes to use this training to ensure accurate claiming. The Commission has also published new guidance on their website under Guidance on fees and funding.
Three new forms to support the schemes have been introduced:
• CLAIM1A for non-advocacy work
• CLAIM5A for advocacy work
• Advocates' Attendance Form for advocates.
If you are an advocate you need to complete the Advocates' Attendance Form:
• for hearings that last for more than an hour or
• when claiming bolt-ons.
The Court needs to verify the information on this form and it is the advocate's responsibility to:
• get the form signed at court by the judge, magistrate or legal adviser and
• keep a copy of the signed form.
The advocate should submit this form with their claim. Copies of signed forms will not be kept by the court. The full list of new and revised forms can be found at:
But if you are wise enough to be a subscriber to the excellent Anya Designs iLaw system you will have these concerns catered for in the latest service pack being despatched this week.


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Mystikal x Mannie Fresh x Freestyle
August 10, 2010
Mystikal was spotted in New Orleans hanging out with producer Mannie Fresh as they "brainstorm" over beats that may or may not appear on Mystikal's post-jail album. The Unpredictable rapper even bust a freestyle that was hotter than cayenne pepper.
Let me put on my A&R cap and say this: If Mystikal grabs hitmakers KLC, Pharrell Williams and Mannie Fresh for his new project, I'm finna to believe that Mystikal will have a classic album.
It's good to see Mystikal and Mannie "brainstorm" over beats. Let's get ready to rumble!
If you are in New Orleans on Aug. 12, check out Mystikal performing at the House of Blues. You can cop tickets HERE.
Y'all ain't ready!

subset: commoncrawl


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Going to play outside, has a significant effect on children in order got boosted for their mental and physical health. Childhood is the basement of everyone's life. This is the reason for which, you shouldn't underestimate playing different type of games with your child.
Parents' responsibility for letting their children to play
Playing outdoor games is also an essential and positive effect on children. Such type of games has a significant impact to lift their physical and psychological abilities. If children will play properly and they will spend some valuable moments in outdoor games, definitely, they will get matured with early age. This is the reason for which, every parent should be more careful in order to make their children trained to go through the games. Presently, maximum children spend a significant portion of the life sitting inside home and enjoying games in computer or they love to have TV programs. These are something those will not only make them dumb, but also creates various different social issues in the future. All those things need to be replaced with outdoor toys for kids and as guardian; you should encourage your children to go for outdoor games.What should guardians do to urge their youngsters to invest more energy playing outside? To start with, realize what the best time recreations are for kids. Luckily, the outside play hardware for kids are outlined in stunning standpoint, work and everything from easy to complex detail of play gear to finish play areas in the patio that are sheltered, tough and shoddy. What's more, indeed, all kids will have a fabulous time with them. Whether your kids are more inspired by conventional play gear like wilderness centers and swing faltering, or incline toward climbing dividers and constructed playhouses, there are modules and frameworks that effortlessly accessible and meet each family needs and spending plan. What's more, exceptional play hardware is additionally accessible for youngsters with uncommon requirements.
Kids outdoor play equipment or indoor play equipment is available for all the children and they are available in different colors along with a composition with different materials. Mainly, these are available in plastic and they all are perfectly designed to enhance the kid's creative ideas those will make their future better. Metal components are mainly padded with rubber and soft plastic for protection. Many popular playgrounds for the backyards and made from the redwood material. This wood is very attractive and durable enough which will worth your investment.Now, this is the time to build the playground for your kids. It will be best to build their playground inside your home premises because; it is not safe to leave them outside from your eyes. Your backyard is the ideal place to build their playground.
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"Denver Electronic Cigarettes offers the latest inventory of the best products in the business. If you're looking for a reliable, educational shop that will help you switch from cigarettes to electronic cigarettes, we're here for you.
We are family owned & operated. Whether you're looking for a basic starter kit as a first time vaper, or if you're looking for some of the latest accessories, come to us first! Denver Electronic Cigarettes currently has two locations now! We're open in Denver, and our newest shop now located in Aurora. We carry all of the following, and much more!
Atomizers/Tanks Replacement parts Batteries & Devices Charges Vaporizer Pens Electronic Cigarettes E-Liquids / E-Juice
If you want to learn more, feel free to contact us at (720) 748-7524!"


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Some of Larry Vickers' more infantile critics assert that he can't know what he's talking about, because "he's fat."
After spending almost a full decade as a Delta Force assaulter in which he survived three helicopter crashes and multiple injuries, he's lucky to be alive and relatively mobile. Many of his peers are crippled, and others are in Arlington National Cemetery.
Don't confuse someone's appearance with their competence. I'd much rather learn from a grizzled old veteran, than a ripped 25-year-old who merely looks the part of an operator.
Tags: Video
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viernes, 27 de enero de 2017
The Dave Brubeck Quartet • Bossa Nova U.S.A
Review by Scott Yanow
With the popularization of bossa nova in the early '60s, practically every recording artist had to have at least one bossa nova album. This effort by the Dave Brubeck Quartet is better than most due to the high quality of the compositions, of which the title cut is best-known. The date's two standards ("This Can't Be Love" and "Trolley Song") also fare well on this upbeat session.
Track Listings
1. Bossa Nova Usa
2. Vento Fresco (Cool Wind)
3. Trolley Song
4. Theme For June
5. Coracao Sensival (Tender Heart)
6. Irnao Amigo (Brother Friend)
7. There'll Be No Tomorrow
8. Cantiga Nova Swing
9. Lamento
10. This Can't Be Love
Dave Brubeck – piano
Paul Desmond – saxophone
Joe Morello – drums
Eugene Wright – double bass
This file is intended only for preview!
I ask you to delete the file from your hard drive after reading it.
Etiquetas: Dave Brubeck, Eugene Wright, Hard Bop, jazz, Joe Morello, Paul Desmond, piano, Piano Jazz, sax, saxo, τζαζ, джаз, דזשאַז, موسيقى الجاز, ジャズ, 爵士乐
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Regardless of which team wins Super Bowl 50 on Sunday in Santa Clara, California, a new coach will join the club of champion coaches. Neither Gary Kubiak of the Broncos nor Ron Rivera of the Panthers has so much as led a team to the Super Bowl before this season, let alone won one.
But both men have previous experience with the big game in other roles.
Kubiak, who took over the Broncos this season after six-plus seasons with the Texans — was the Broncos backup quarterback to John Elway — now the team's general manager — when Denver lost three Super Bowls during the late 1980s. He also won three championships in the 1990s, first with the 49ers in 1994 and then with the Broncos in 1997 and 1998.
Rivera, in his fifth season with Carolina, was a member of the 1985 Bears team that capped an 18-1 season with a victory in Super Bowl XX, playing linebacker. After transitioning into coaching, he served as defensive coordinator for the Bears when they lost to Peyton Manning's Colts in 2006.


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When I displayed a �Countdown to Kickoff� T-shirt near my Gazette desk about three years ago, Charlotte 49ers football was still nearly 1,000 days away. Administrators in board rooms in Raleigh had approved the idea of UNC Charlotte fielding a collegiate team, but it was still just a concept. As a proud alumnus of the school, I knew football was coming, and I was excited. But it didn�t exactly seem �real.�
Since then, it�s become much more tangible. The team has hired a coaching staff, designed a helmet and uniforms, signed recruits and practiced for about two years, and intramural fields on the southern edge of campus gave way to a new football stadium complex.
When football kicks off on Aug. 31, it will be the biggest athletic event the campus of UNC Charlotte has ever seen � and likely the biggest event period. Charlotte has �officially� had football since it was approved in 2008, but it becomes real Saturday. I�m excited about the tailgates and the traditions that come along with college football, but possibly my favorite part of Charlotte football is how it even got to this point in the first place.
Like a number of other universities, there are plenty of myths about why UNC Charlotte never had a football team.
Stories about the young child of a school founder being killed while playing the sport or of a wealthy benefactor insisting on no football eventually were the prevailing legends. The primary reason the school hasn�t had football until now though, is a lot more simple. Economic concerns aside, there just wasn�t an organized push for it.
The school did field a football team in the 1940s, but that only lasted a short time. Organized groups tried several times to resurrect football, but to no avail. In 2006, a group of 15 students and alumni started a campaign that eventually led to campus wide vote asking students if they would be willing to pay increased fees to support a football team. More students participated in this vote than any other vote in the school�s history, and the result was overwhelming approval.
Widespread student approval led to numerous committee meetings and public forums, which eventually led to Chancellor Phillip Dubois officially recommending football to the UNC system board of trustees. The only condition though, was that fans raise the first $5 million for a stadium complex. Fans would not only meet, but surpass that mark.
When the school announced the addition of football, they also announced Forty-Niner Seat Licenses � similar to the PSLs (private seat licenses) of the Carolina Panthers. In short, just an expensive license that allows you to purchase 49ers football tickets. Many called that a risky proposition, especially given the current economic climate. All 5,000 FSLs were sold, and several hundred additional season tickets sold out within hours. Students have already requested more than their 7,500 ticket allotment, so they�ll be taking part in a lottery system.
Single game ticket aren�t even on sale, and school administrators have no plans to introduce them. Your only option now to purchase tickets on a game-by-game basis is the secondary market � where a ticket to the inaugural game has sold for an average of about $140. At least for this first season, Charlotte 49ers football is a pretty hot ticket.
I know it�s the inaugural season, and this is a special time � so it�s hard to tell if this level of excitement will endure. But I�ve already seen the school�s students and alumni more energized than I ever have before. Even the surrounding community seems more aware of the school. I�ve had people comment on Charlotte 49ers football at a gas station or stoplight when they see the license plate on my car. Carolina Panthers owner Jerry Richardson believes so much in the program that he donated $10 million just to have his name on the stadium.
It seems like everything has fallen into place better than expected so far. But there have been plenty of detractors along the way. People that it couldn�t be done in this economy, that the city of Charlotte�s sports fans are too fickle to support a team, and that it would damage the school�s academic integrity.
Former UNC system president Dick Spangler even went so far as to say that college football should be left to the likes Chapel Hill and North Carolina State, and that UNC Charlotte should �work on its intramurals.�
I�ll stop just short of saying that the school �needed� football. But UNC Charlotte was one of largest schools in the nation without a football program. An essential college experience for so many just wasn�t available there.
College football will bring UNC Charlotte alumni back to campus like no other sport has before, will give the school a brand new level of exposure, and be a spectacle like the campus has never seen.
Plenty of milestones have already been reached for the program: the first coach, the first player, the first uniform, and the first piece of ground broken for the on-campus stadium. The only milestone left will be accomplished at noon Saturday.
Gazette newsroom clerk Artie Beaty (class of 2006) can be reached at firstname.lastname@example.com or twitter.com/aobeaty.


text: Stone School Condominiums are located off Stone School Rd. between I-94 and Ellsworth in Ann Arbor, MI. The community features 55 townhomes, built in the 2000s, managed by Midwest Property. The homes offer 2-4 bedrooms with a children's play area and outside parking.Stone School is an easy walk to highly acclaimed Ann Arbor public elementary and middle schools. Also close to Lillie Park, Swift Run Dog Park, shopping on Packard, Michigan Ave and Carpenter, and US-23.


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IUCN, in partnership with the Governments of Austria, Italy, Luxembourg, and Spain recently supported Sirubai Voko Tribe Association, with a solar project.
Sirubai Voko Tribe Association (SVTA) at Pusiju village, Vella la Vella Island, Western Province has praised IUCN, in partnership with the Governments of Austria, Italy, Luxembourg, and Spain with this small grant.
"Titled Pusiju Community Copra Buying Solar Project, the main aim of the project was to create economic opportunity for local people to meet their needs whilst sacrificing their forest for conservation" explained Henry Kaniki.
"The small grant is up to USD20,000, and it is targeted for energy focused project on community micro-enterprise development and conservation nature and providing nature based solutions to develop challenges" Mr Kaniki continued.
Kaniki said the SVTA is a community based organisation from Pusiju village, Vella La Vella Island that was initiated by the community themselves.
Meanwhile team leader Mr Tapera Bird of Superfly Limited says his team is very excited about the partnership.
He said his company is glad to see sustainable development happening in very remote places such as Pusiju community.
Also speaking on the occasion, Chief of Sirubai Voko Tribe Caleb Bukiri acknowledged the support received from IUCN.
"This has become a history for my people" he said.
Mr Bukiri said the project will not only support the people of Sirubai Voko Tribe but will also benefit the entire community of Sirubai region.
"Over the past years we have received partners (NGO), donors, Government Ministries, Church leaders on our shore so this project will also benefit the general public"
Also Mrs Keithy Tovakera, expressed her gratitude towards the project as it will empower the women and girls in creating livelihood activities that will in return meet the needs of their family.
The project is expected to be officially launched at the end of this year and SVTA is hoping to get the donor and relevant partners to the project site to witness the project success.
Source: Alfred Pagepitu, The Island Sun


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Yet, being an attorney, I make an effort to stay impartial about certain subjects, and a number of the subjects would be the legalization of marijuana. Marijuana and the results that it has on any specified individual is not my own area of expertise, but advocating that you don't participate in any prohibited activities is decidedly one of my responsibilities as an attorney. Much to the disappointment of most, the use of marijuana continues to be illegal in the State of Florida. Consequently, the way I feel about its usage is insignificant.
Now that I have clearly established that I am neither an advocate for, nor a detractor ofthe use of bud beyond the limitations of this law, I want to discuss the subject in greater detail.cbd oil vape
For almost four thousand decades, Cannabis is used as an entheogen; this really can be, like a substance used to cause a spiritual experience or awakening. Even though it is hard to differentiate where this practice originated, you'll find historical records that indicate it has been cultivated and chosen ever since humans became increasingly an agrarian society. This substantiation was found in a lot of countries which include Africa, China, Greece, India, and Nepal, in addition to the others.
Along with its own use as an entheogen, Cannabis has been employed in a variety of other ways such as for example an industrial fiber. This fiber can be used in making fabrics, and clothing even though when used for clothing, it's usually along with other types of fibers. It is also used in some food items. It's figured prominently in pop culture at the kind of songs and films, as well as learning to be a multi-billion buck industry here in the U. S. alone.
In early 1900s, it became classified as a habitforming drug by the New York Board of Health. Also during the early years of the 20th Century, controversy started to brew nationwide over the effects that it has on individuals. You can find many individuals who felt that it led to increased sexual appetite, violent behavior, irrationality, as well as according to all the N. Y. Board of Health, habituation. As the result of concerns with this type, the U. S. government started to require that services and products which comprised its by-products must be labelled"toxin"
Even though this action didn't fundamentally criminalize possession of marijuana, it did impose penalties and enforcement provisions up on individuals who were included in the use and sale of it. It was a catch 22 situation – you also had to pay tax on it if you purchased it or used it, in attempting to achieve this, you're admitting that you have of it without paying tax on it.
This act also established a classification system for a variety of drugs with Schedule 1 drugs being probably the very closely regulated. This class of drugs includes prohibited substances based upon concern with safety and the amount of dependence potential because they possess a high probability of misuse without a licensed medical purpose. Marijuana drops under this classification. Though some states have ruled that it can, in fact, offer medical benefits, this really is really a national act that does not dictate the nations' individual decisions concerning the issue.
The debate over whether Cannabis is harmful has been hotly contested for at least four decades. In addition, there has been a continuous debate for the previous twenty decades or so regarding whether or not marijuana provides medicinal benefits. Recent research appears to confirm that it can, but there are a number of researchers that can't actually agree upon the data which the research provides. The studies that have been run up on this unpretentious weed have now been numerous and also the data that is faked appears to frequently be enormously different.
What has been found to be true is that marijuana contains cannabinoids such as tetrahydrocannabinol (THC). This and other chemical compounds found in Cannabis act upon the mind. THC is an analgesic so that it can help to decrease pain levels while also increasing appetite and relaxation yet reduces degrees of aggression. The reduction in pain levels is the reason it's often suggested for use in cancer patients, and also the rise in appetite is why it is often suggested for both HIV/AIDS patients. But because you can find other psychoactive effects that are not understood, medical usage is still hotly contested.


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I participated in some courses in Coursera, with very interesting subjects. For the first time I decided to enroll in a course in edx, and I ended up in a Microsoft Data Camp course on R. The course is very basic, mostly on syntax than in statistics. Good enough. The course is based in 5 to 6 minutes videos, and then some exercises done online. Although too basic, the course was interesting enough for me, as I did not know anything on R.
But what really annoyed me was the final evaluation. First, the instructions claim we will have 4 minutes per question… but the timer starts at 3 minutes. Well.. Microsoft… Then, instead of having questions on using R for some interesting tasks (take this data, change it, then plot) the exam is a set of puzzle questions, with placeholder we need to fill to obtain some result. Yes, when using R we will be faced with puzzles. And worse, there is no pause button. I understand you might want to limit the time to answer to each question, but why not to pause in between questions? Specially when you are at home and someone rings your door bell. Well, after 20 minutes or so at the door, I returned to the exam, and still got 75%.
And, OK, I did not pay for a verified certificate. But at least you could show a digital certificate we might print and show. OK, I'll get back to Coursera. See you, edX!


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"After years of daydreaming, planning and saving we decided we were ready to remodel our home. Our children gone, the drama of the remodel would only affect the two of us.
We had heard of 36th Avenue Design|Build's work the year before, seen some examples of recent projects and shared the design in a first meeting. They were quick to grasp what we wanted to achieve and in a few meetings with the architect we were set for demolition. A major remodel really is a leap of faith – you commit your time and other resources to the discretion of the artist and hope that your vision is shared. Add to that the unknowns behind the walls and ceiling suddenly revealed, and you can easily become overwhelmed.
They helped us through these events identifying solutions to choose from, both practical and creative. The result far exceeded our dreams. It gives us energy and peace simultaneously. As an expression of the collaboration in matching materials with design the result is stunning. We highly recommend 36th Avenue Design|Build."
John and Carol / View our project


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AMP Clinic
AMP Clinic is the first of its kind in alternative therapy in Weight loss and Pain relief management.
A unique and scientific method for "Subtle Energy" diagnosis through latest technologies;
- Acugraph
- Nadi Tarangini
- Kirlian Aura
- Biowell Therapy
Based on the teachings of ancient yogic sciences and inferences drawn by the latest technology in place. The diagnostic and healing process involves reading of your;
- Aura
- Chakra
- Energy Bodies
- Energy Balance
The process is done by taking finger prints through Kirlian camera which gives a detailed report of Chakras i.e., energy plexus in your body.
The report of personal energetic homeostasis by measuring;
- Energy field
- Health parameters
- Present disease
- Diseases which could Manifest in 6 to 7 months
Treatment is achieved through acugraph technology; A specialized software USA which generates a complete report of;
- Diseases
- Deficiency of organs
- Imbalance of the five elements in the body
AMP Clinic Offers : A Holistic and drug-less therapy through Acupuncture with no side-effects.
A Holistic and drug-less therapy through Acupuncture with no side-effects and also Yoga therapy.


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Salvatore Ferragamo chose New York for the first time to stage its resort show this season. The James B. Duke mansion on Fifth Avenue on the Upper East Side, built in 1912, served as the backdrop, and by show time, a throng had gathered outside screaming in anticipation of Eva Mendes' arrival. Wearing a nude and white Ferragamo cocktail dress, she stepped out of a town car, waved to the crowd, and ascended the mansion's staircase. Emma Roberts, Freida Pinto and Ashley Greene also took a front row perch in the Beaux Arts mansion's grand foyer for the show.
More than a few guests muttered under their breath, "I guess the recession is over," admiring the imposing space, which had been filled with Dutch hydrangeas, delphiniums and white peonies. The timing for this grand presentation was certainly premeditated -- it served as an unofficial kickoff for Ferragamo's public offering on the Milan Stock Exchange. The brand seems to adhering to the age old mantra of you have to spend money to make money.
Karlie Kloss, Mariacarla Boscono, Karolina Kurkova and Vanessa Traina -- among others -- ascended the mansion's staircase in looks inspired by nautical fashions and 1930s screen sirens (the '30s also served as inspiration for Ferragamo's men's Spring 2012 collection). These were the kind of clothes that one could imagine Doris Duke herself (the late heiress and former inhabitant of the mansion) wearing throughout her day -- a point certainly not lost on Creative Director Massimiliano Giornetti. Giornetti has been heading womenswear at Ferragamo for precisely a year, and he seems particularly interested in emphasizing the brand's glamorous history.
There were cotton skirts and dresses with unique trompe l'oeil effects, perfectly cut cream gabardine pantsuits, cashmere gold and ivory striped sweaters, a knit jumpsuit paired with an anchor bedazzled in Swarovski crystals and fluid satin gowns. Stand-outs were a navy satin top with piping detail and a matching satin pant (right on trend with the pajama look happening at the moment) and a beaded fringe evening gown that is sure to make a red carpet appearance. Art Deco jewelry from Fred Leighton complimented the collection, and captain hats with metal chain detailing and oversized navy sun hats added some fun to the show.
Of course, the bread and butter of the Ferragamo house is accessories, and they were certainly not an after thought with this collection. There were duffle bags made with interlocking chains, mirror-lined minaudières, velvet clutches, wedges with glass mosaic heels and azure satin espadrilles.


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Old woodworking planes on ebay
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Pending Policies - Surgery
Hematopoietic Stem-Cell Transplantation for Breast Cancer
Effective Date:06-15-2018
Autologous or allogeneic hematopoietic stem-cell transplantation is considered experimental, investigational and/or unproven to treat any stage of breast cancer.
NOTE: See Medical Policy SUR703.002 Hematopoietic Stem-Cell Transplantation (HSCT) or Additional Infusion Following Preparative Regimens (General Donor and Recipient Information) for detailed, descriptive information on HSCT related services.
Hematopoietic Stem-Cell Transplantation
Hematopoietic stem-cell transplantation (HSCT) refers to a procedure in which hematopoietic stem-cells are infused to restore bone marrow function in cancer patients who receive bone-marrow-toxic doses of cytotoxic drugs with or without whole-body radiation therapy. Hematopoietic stem-cells may be obtained from the transplant recipient (autologous HSCT) or from a donor (allogeneic HSCT). 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 "naïve" and thus are associated with a lower incidence of rejection or graft-versus-host disease (GVHD).
Immunologic compatibility between infused hematopoietic stem-cells and the recipient is not an issue in autologous HSCT. However, immunologic compatibility between donor and patient is a critical factor for achieving a good outcome of allogeneic HSCT. 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 Class I and Class II loci on chromosome 6. Depending on the disease being treated, an acceptable donor will match the patient at all or most of the HLA loci (with the exception of umbilical cord blood).
HSCT in Solid Tumors in Adults
The use of high-dose chemotherapy (HDC) and HSCT, instead of standard-dose chemotherapy, has been used in an attempt to prolong survival in women with high-risk nonmetastatic and metastatic breast cancer.
HSCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults continues to be largely experimental. Initial enthusiasm for the use of autologous transplant with the use of HDC and stem-cells for solid tumors has waned with the realization that dose intensification often fails to improve survival, even in tumors with a linear-dose response to chemotherapy. With the advent of reduced-intensity allogeneic transplant, interest has shifted to exploring the generation of alloreactivity to metastatic solid tumors via a graft-versus-tumor effect of donor-derived T cells.
The U.S. Food and Drug Administration (FDA) regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research (CBER), under Code of Federal Regulation (CFR) title 21, parts 1270 and 1271. (26) Hematopoietic stem-cells are included in these regulations.
High-dose chemotherapy (HDC) followed by hematopoietic stem-cell transplant (HSCT) (i.e., blood or marrow) is an effective treatment modality for many patients with certain malignancies and non-malignancies. The rationale of this treatment approach is to provide a very dose-intensive treatment in order to eradicate malignant cells followed by rescue with peripheral blood, bone marrow, or umbilical cord blood stem-cells.
The literature search of the MedLine database for this medical policy was updated through May 2017. The following is a summary of the key literature to date.
History of HSCT for Breast Cancer
In the late 1980s/early 1990s, initial results of phase II trials for breast cancer and autologous HSCT were promising, showing high response rates in patients with metastatic disease who underwent high-dose consolidation, with a subset of up to 30% remaining disease-free for prolonged periods. (1) In the early 1990s, larger prospective comparisons of conventional-dose chemotherapy to high-dose therapy with HSCT were initiated but accrued slowly, with up to a decade from initiation to the reporting of results. (1) The first results from randomized trials at a single institution in early stage and metastatic disease showed survival benefits but were ultimately shown to have been based on fraudulent data. (1) In the interim, however, the treatment became almost standard of care, while many patients received high-dose therapy off protocol, further reducing accrual to ongoing randomized trials. (1) The results of the randomized trials were presented beginning in 1999 and showed little survival benefit; subsequently, the number of HSCT procedures performed for breast cancer decreased from thousands every year to only a few. (1)
Autologous HSCT
The PBT-1 trial randomly assigned patients with a complete response (CR) or partial response (PR) to induction therapy for previously untreated metastatic breast cancer to autologous HSCT (n=101) or to conventional-dose maintenance chemotherapy (n=83) for up to 2 years. (2) Of 553 patients enrolled and given initial induction therapy, only 310 achieved a PR (n=252) or CR (n=58), and only 199 were randomized. Of 72 partial responders assigned to the HSCT arm after initial induction therapy, only 5 (7%) were converted to CR. Median survival (24 months versus 26 months, respectively) and overall survival (OS) at 3 years (32% versus 38%, respectively) did not differ between arms. There also were no statistically significant differences between arms in time to progression or progression-free survival (PFS) at 3 years. While treatment duration was substantially shorter for those randomly assigned to HSCT, acute morbidity was markedly more severe than after conventional-dose maintenance.
During 2003 and 2004, 4 trials reported final outcomes analyses from randomized comparisons of autologous HSCT versus conventional-dose chemotherapy for adjuvant therapy of high-risk nonmetastatic breast cancer. (3-6) Two of the studies involved women with at least 4 positive axillary lymph nodes, and the other 2 involved at least 10 positive lymph nodes. The 4 studies pooled included 2337 patients.
Evidence from these trials did not support the conclusion that autologous HSCT improved outcomes compared with conventional-dose adjuvant therapy, because no OS difference was seen in any of the studies. An accompanying editorial briefly reviewed and commented on factors contributing to the diffusion of autologous HSCT into routine practice of the treatment of certain breast cancer patients, without adequate testing in randomized controlled trials (RCTs). (7)
A Cochrane systematic review and meta-analysis published in July 2005 pooled data from 6 RCTs on metastatic breast cancer reported through November 2004 (438 randomly assigned to autologous HSCT, 412 to conventional-dose therapy). (8) The relative risk (RR) for treatment-related mortality (TRM) was significantly higher in the arm randomly assigned to HSCT (15 deaths versus 2 deaths; RR=4.07; 95% confidence interval [CI], 1.39 to11.88). Treatment-related morbidity also was more severe among those randomly assigned to HSCT. OS did not differ significantly between groups at 1, 3, or 5 years posttreatment. Statistically significant differences in event-free survival (EFS) at 1 year (RR=1.76; 95% CI, 1.40 to 2.21) and 5 years (RR=2.84; 95% CI, 1.07 to 7.50) favored the HSCT arms. Only 1 of the 6 included trials had followed all patients for at least 5 years. Reviewers recommended further follow-up for patients randomized in the other 5 trials. They also concluded that, in the interim, patients with metastatic breast cancer should not receive HSCT outside of a clinical trial because available data showed greater TRM and toxicity without improved OS.
A second Cochrane systematic review and meta-analysis, also published in July 2005, included data from 13 RCTs on patients with high-risk (poor prognosis) early breast cancer (2535 randomly assigned to HSCT, 2529 to conventional-dose therapy). (9) TRM was significantly greater among those randomly assigned to HDC (65 deaths) than to autologous cell transplantation (4 deaths; RR=8.58; 95% CI, 4.13 to 17.80). Treatment-related morbidity also was more common and more severe in the high-dose arms. There were no significant differences between arms in OS rates at any time after treatment. EFS was significantly greater in the HSCT group than the HSCT group at 3 years (RR=1.12; 95% CI, 1.06 to 1.19) and 4 years (RR=1.30; 95% CI, 1.16 to 1.45) after treatment. However, the 2 groups did not differ significantly with respect to EFS at 5 and 6 years' posttreatment. Quality-of-life scores were significantly worse in the HSCT arms than in controls soon after treatment, but differences were no longer statistically significant by 1 year. Reviewers concluded that available data were insufficient to support routine use of HSCT for patients with poor-prognosis early breast cancer.
Hanrahan et al., with a median follow-up of 12 years, demonstrated no recurrence-free or OS advantage for patients with high-risk primary breast cancer treated with autologous HSCT after standard-dose chemotherapy (n=39) versus standard chemotherapy alone (n=39). (10) Coombes et al. reported on autologous HSCT as adjuvant therapy for primary breast cancer in women free of metastatic disease, with a median follow-up of 68 months. (11) A total of 281 patients were randomly assigned to receive standard chemotherapy or HDC with HSCT. They found no significant difference in relapse-free survival or OS (OS hazard ratio [HR], 1.18; 95% CI, 0.80 to 1.75; p=0.40).
A systematic review and meta-analysis published in 2007 included RCTs comparing autologous HSCT with standard-dose chemotherapy in women with early, poor-prognosis breast cancer, which included 13 trials to September 2006 (total N=5064 patients). (12) Major conclusions were that, at 5 years, EFS approached statistical significance for the high-dose group, but no OS differences were seen. There were more transplant-related deaths in the high-dose group. The overall conclusion was that there was insufficient evidence to support routine use of autologous HSCT for treating early, poor-prognosis breast cancer.
Crump et al. reported the results of a randomized trial of women who had not previously been treated with chemotherapy and had metastatic breast cancer or locoregional recurrence after mastectomy. (13) After initial response to induction therapy, 112 women were allocated to standard chemotherapy and 112 to autologous HSCT. After a median follow-up of 48 months, 79 deaths were observed in the high-dose group and 77 in the standard chemotherapy group. No difference in OS was observed between groups after a median follow-up of 48 months, with a median OS of 24 months in the HSCT group (95% CI, 21 to 35 months) and 28 months for the standard chemotherapy group (95% CI, 22 to 33 months; HR=0.9; 95% CI, 0.6 to 1.2; p=0.43).
Biron et al. reported the results of a phase 3, open, multicenter, prospective trial of women with metastatic breast cancer (and/or local or regional relapse beyond curative treatment by surgery or radiotherapy). (14) After a CR or at least 50% PR to induction therapy, 88 women were randomly assigned to HSCT and 91 to no further treatment. No OS difference was seen between groups, with 3-year survival of 33.6% in the high-dose group and 27.3% in the observation group (p=0.8).
Zander et al. reported survival data after 6 years of follow-up (15) on a trial that had previously reported to 3.8 years of follow-up. (6) Women with surgically resected breast cancer and axillary lymph node dissection with 10 or more positive axillary lymph nodes but no evidence of metastatic disease were randomly assigned to standard chemotherapy (n=152) or HSCT (n=150). No difference in OS was observed; the estimated 5-year OS rate in the standard arm was 62% (95% CI, 54% to 70%) and 64% (95% CI, 56% to 72%) in the high-dose transplant group.
Nieto and Shpall (2009) performed a meta-analysis of all randomized trials published or updated since 2006, focusing on those that compared HDC with standard-dose chemotherapy for high-risk primary breast cancer. (16) The meta-analysis of 15 randomized trials involving patients with high-risk primary breast cancer or metastatic disease (total N=6102 patients) detected an absolute 13% EFS benefit in favor of HDC and autologous HSCT (p<0.001) at a median follow-up of 6 years. The absolute differences in disease-specific and OS was not statistically significant (7% and 5%, respectively). Subset analyses suggested that HDC could be particularly effective in patients with triple-negative tumors (hormone receptor and HER2-negative [human epidermal growth factor receptor 2]). The authors concluded that HDC remains a valid research strategy in certain subpopulations with high-risk primary breast cancer (e.g., those with triple-negative tumors).
Berry et al. performed a meta-analysis with individual patient data from 15 randomized trials comparing autologous HSCT with HDC (n=3118) to standard chemotherapy (n=3092) for patients with high-risk primary breast cancer. (17) A survival analysis was adjusted for trial, age, number of positive lymph nodes, and hormone receptor status. HSCT was associated with a nonsignificant 6% reduction in risk of death (HR=0.94; 95% CI, 0.87 to 1.02; p=0.13) and a significant reduction in the risk of recurrence (HR=0.87; 95% CI, 0.81 to 0.93; p<0.001). Toxic death was higher in the HSCT group (6% [72/1207] deaths in these trial arms versus 1.4% [17/1261] deaths in the standard therapy arms). In a subgroup analysis, the authors investigated whether age, number of positive lymph nodes, tumor size, histology, hormone receptor status, or HER2 status impacted survival when comparing HSCT to standard treatment. The authors found that HER2-negative patients receiving HSCT had a 21% reduction in the risk of death and HER2-negative and hormone receptor negative patients receiving HSCT had a 33% reduction in the risk of death. In their discussion, the authors noted that this relation could be spurious due to the amount of missing data on HER2 status and suggested that HSCT is unlikely to show much benefit in these subgroups of patients.
A meta-analysis by Wang et al. included aggregate data from 14 trials (total N=5747 patients) published since March 2010. (18) Clinical trials of patients receiving HSCT as a first-line treatment for primary breast cancer were eligible for inclusion. A higher TRM was found among the patients who received HSCT compared with standard chemotherapy (RR=3.42; 95% CI, 1.32 to 8.86). OS did not differ significantly between groups (HR=0.91; 95% CI, 0.82 to 1.00) for the HSCT compared with standard treatment. Risk of secondary, non-breast cancer was higher in the HSCT group (RR=1.28; 95% CI, 0.82 to 1.98). DFS was better in the HSCT group than in the chemotherapy-alone group (RR=0.89; 95% CI, 0.79 to 0.99). Patients receiving HSCT had a greater risk of dying during remission than patients treated with nonmyeloablative chemotherapy because of regimen toxicity. This increase in TRM may help explain why there was no observed OS benefit for patients receiving HSCT when disease-free survival was observed to be superior to standard chemotherapy.
In 2013, the Italian Group of Bone Marrow and Hematopoietic Stem-Cell Transplantation and Cellular Therapy (GITMO) published registry data on 415 patients with metastatic breast cancer who received HDC and autologous HSCT between 1990 and 2005. (19) More than 95% of the transplants performed used peripheral blood stem-cells. Sixteen percent of patients received a tandem transplant. Estrogen receptor (ER) status was known in 328 patients, 65% of whom were ER positive. HER2 expression data were insufficient for subset analysis. After a median follow-up of 27 months (range, 0-172 months), PFS at 5 and 10 years was 23% and14% and OS was 47% and 32%, respectively. The authors reported statistically significant survival benefits in patient subgroups including those with ER-positive tumors and those without visceral metastases; however, these are established positive prognostic factors compared with factors for patients with ER-negative tumors and visceral metastases, respectively. In addition, the authors did not report which patients received hormonal therapy, nor was it known if/which patients received targeted HER2 therapy, and it is unclear what impact on survival therapies other than HSCT may have had.
In 2014, GITMO published registry data on the use of adjuvant HDC with autologous HSCT in 1183 patients with high-risk primary breast cancer (≥3 involved lymph nodes), treated between 1990 and 2005. (20) Data on ER and HER2 status were available for 85% and 48% of patients, respectively. Most patients with hormone receptor-positive tumors received tamoxifen after HSCT. The median lymph node involvement at surgery was 15 (range, 4-63). More than 95% of the patients received peripheral blood-mobilized stem-cells. After a median follow-up of 7.1 years, disease-free survival was 9.6 years, with 65% of patients free of disease at 5 years. Median OS was not reached, with 75% of patients alive at 5 years posttransplantation. Subgroup analysis showed significantly better OS in endocrine responsive tumors and in patients who received multiple transplant procedures. Transplant-related mortality was 0.8% and late cardiac and secondary tumor-related mortality were approximately 1% overall.
Tandem Autologous Transplantation
Kroger et al. compared single versus tandem autologous HSCT in 187 patients with chemotherapy-sensitive metastatic breast cancer. (21) Only 52 of 85 patients completed the second HDC cycle in the tandem arm, mostly due to withdrawal of consent (most common reason), adverse effects, progressive disease, or death. The rate of CR was 33% in the single-dose arm versus 37% in the tandem arm (p=0.48). Although there was a trend toward improved PFS after tandem HSCT, median OS tended to be greater after single (29 months) versus tandem HDC (23.5 months; p=0.4). The authors concluded that tandem HSCT cannot be recommended for patients with chemotherapy-sensitive metastatic breast cancer because of a trend for shorter OS and higher toxicity compared with single HSCT.
Schmid et al. published results of 93 patients without prior chemotherapy for metastatic breast cancer who were randomly assigned to standard-dose chemotherapy or double HDC with autologous HSCT. (22) The primary study objective was to compare CR rates. Objective response rates for patients in the high-dose group were 66.7% versus 64.4% for the standard group (p=0.82). There were no significant differences between the 2 treatments in median time to progression, duration of response, or OS (double high-dose arm, 26.9 months versus standard arm, 23.4 months; p=0.60).
Allogeneic HSCT
To date, allogeneic HSCT for breast cancer has mostly been used in patients who have failed multiple lines of conventional chemotherapy. (23)
Ueno et al. reported the results of allogeneic HSCT in 66 women with poor-risk metastatic breast cancer from 15 centers who underwent transplantation between 1992 and 2000. (24) Thirty-nine (59%) received myeloablative and 27 (41%) received reduced-intensity conditioning (RIC) regimens. A total of 17 (26%) patients had received a prior autologous HSCT. Median follow-up time for survivors was 40 months (range, 3-64 months). TRM was lower in the RIC group (7% versus 29% at 100 days; p=0.03). PFS at 1 year was 23% in the myeloablative group and 8% in the RIC group (p=0.09). OS rates after myeloablative conditioning versus RIC were 51% (95% CI, 36% to 67%) versus 26% (95% CI, 11% to 45%; p=0.04) at 1 year, 25% (95% CI, 13% to 40%) versus 15% (95% CI, 3% to 34%; p=0.33) at 2 years, and 19% (95% CI, 8% to 33%) versus 7% (95% CI, <1% to 25%; p=0.21) at 3 years, respectively.
Fleskens et al. reported the results of a phase 2 study of 15 patients with metastatic breast cancer treated with human leukocyte antigen (HLA)-matched reduced-intensity allogeneic HSCT. (25) Median patient age was 49.5 years (range, 39.7-60.8 years), and all patients had been extensively pretreated and had undergone at least 1 palliative chemotherapy regimen for metastatic disease. TRM was 2 (13%) of 15. One-year PFS was 20%, and 1- and 2-year OS were 40% and 20%, respectively. The authors noted no objective tumor responses but concluded that the relatively long PFS suggested a graft-versus-tumor effect.
Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed in Table 1.
Table 1. Summary of Key Trials
NCT Number
Trial Name
Planned Enrollment
Completion Date
High-dose Alkylating Chemotherapy in Oligo-metastatic Breast Cancer Harboring Homologous Recombination Deficiency
Jul 2019
Autologous Hematopoietic Stem-cell Transplantation as Adjuvant Treatment for Triple Negative Breast Cancer Patients
Nov 2017
Chemotherapy Followed by Peripheral Stem-cell Transplantation in Treating Metastatic Triple-negative Breast Cancer
Dec 2017
Table Key:
NCT: National Clinical Trial.
Practice Guidelines and Position Statements
National Comprehensive Cancer Network (NCCN)
NCCN guidelines (v2.2017 – April 6, 2017) do not address the use of HSCT in the treatment of breast cancer. (27)
Summary of Evidence
Randomized trials of autologous hematopoietic stem-cell transplantation (HSCT) versus standard dose-chemotherapy for patients with high-risk nonmetastatic or metastatic breast cancer have not shown a survival advantage with HSCT, and have shown greater treatment-related mortality and toxicity. Therefore, autologous HSCT is considered experimental, investigational and/or unproven for this indication.
Nonrandomized studies using reduced-intensity or myeloablative allogeneic HSCT for metastatic breast cancer have suggested a possible graft-versus-tumor effect, but remains experimental, investigational and/or unproven for this indication.
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CPT/HCPCS/ICD-9/ICD-10 Codes
The following codes may be applicable to this Medical policy and may not be all inclusive.
CPT Codes
36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38222, 38230, 38232, 38240, 38241, 38242, 38243, 81265, 81266, 81267, 81268, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86805, 86806, 86807, 86808, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86828, 86829, 86830, 86831, 86832, 86833, 86834, 86835, 86849, 86950, 86985, 88240, 88241
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The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
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A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Vogl DT, Stadtmauer EA. Editorial: high-dose chemotherapy and autologous hematopoietic stem-cell transplantation for metastatic breast cancer: a therapy whose time has passed. Bone Marrow Transplant. Jun 2006; 37(11):985-7. PMID 16708060
2. Stadtmauer EA, O'Neill A, Goldstein LJ, et al. Convention-dose chemotherapy compared with high-dose chemotherapy plus autologous hematopoietic stem-cell transplantation for metastatic breast cancer. Philadelphia Bone Marrow Transplant Group. N Engl J Med. Apr 13 2000; 342(15):1069-76. PMID 10760307
3. Leonard RC, Lind M, Twelves C, et al. Conventional adjuvant chemotherapy versus single-cycle, autograft-supported, high-dose, late-intensification chemotherapy in high-risk breast cancer patients: a randomized trial. J Nat Canc Inst. Jul 24 2004; 96(14):1076-83. PMID 15265969
4. Rodenhuis S, Bontenbal M, Beex LV, et al. High-dose chemotherapy with hematopoietic stem-cell rescue for high-risk breast cancer. N Engl J Med. Jul 3 2003; 349(1):7-16. PMID 12840087
5. Tallman MS, Gray R, Robert NJ, et al. Conventional adjuvant chemotherapy with or without high-dose chemotherapy and autologous stem-cell transplantation in high-risk breast cancer. N Engl J Med. Jul 3 2003; 349(1):17-26. PMID 12840088
6. Zander AR, Kroger N, Schmoor C, et al. High-dose chemotherapy with autologous hematopoietic stem-cell support compared with standard-dose chemotherapy in breast cancer patients with 10 or more positive lymph nodes: first results of a randomized trial. J Clin Oncol. Jun 15 2004; 22(12):2273-83. PMID 15111618
7. Hortobagyi GN What is the role of high-dose chemotherapy in the era of targeted therapies? J Clin Oncol. Jun 15 2004; 22(12):2263-6. PMID 15111620
8. Farquhar C, Marjoribanks J, Basser R, et al. High dose chemotherapy and autologous bone marrow or stem-cell transplantation versus conventional chemotherapy for women with early poor prognosis breast cancer. Cochrane Data System Rev. 2005; (3):CD003139. PMID 16034887
9. Farquhar C, Marjoribanks J, Basser R, et al. High dose chemotherapy and autologous bone marrow or stem-cell transplantation versus conventional chemotherapy for women with metastatic breast cancer. Cochrane Data System Rev. 2005; (3):CD003142. PMID 16034886
10. Hanrahan EO, Broglio K, Frye D, et al. Randomized trial of high-dose chemotherapy and autologous hematopoietic stem-cell support for high-risk primary breast carcinoma: follow-up at 12 years. Cancer. Jun 1 2006; 106(11):2327-36. PMID 16639731
11. Coombes RC, Howell A, Emson M, et al. High dose chemotherapy and autologous stem-cell transplantation as adjuvant therapy for primary breast cancer patients with four or more lymph nodes involved: long-term results of an international randomized trial. Ann Oncol. May 2005; 16(5):726-34. PMID 15817602
12. Farquhar CM, Marjoribanks J, Lethaby A, et al. High dose chemotherapy for poor prognosis breast cancer: systematic review and meta-analysis. Cancer Treat Rev. Jun 2007; 33(4):325-37. PMID 17382477
13. Crump M, Gluck S, Tu D, et al. Randomized trial of high-dose chemotherapy with autologous peripheral-blood stem-cell support compared with standard-dose chemotherapy in women with metastatic breast cancer: NCIC MA.16. J Clin Oncol. Jan 1 2008; 26(1):37-43. PMID 18025439
14. Biron P, Durand M, Roche H, et al. Pegase 03: a prospective randomized phase III trial of FEC with or without high-dose thiotepa, cyclophosphamide and autologous stem-cell transplantation in first-line treatment of metastatic breast cancer. Bone Marrow Transplant. Mar 2008; 41(6):555-62. PMID 18037940
15. Zander AR, Schmoor C, Kroger N, et al. Randomized trial of high-dose adjuvant chemotherapy with autologous hematopoietic stem-cell support versus standard-dose chemotherapy in breast cancer patients with 10 or more positive lymph nodes: overall survival after 6 years of follow-up. Ann Oncol. Jun 2008; 19(6):1082-9. PMID 18304964
16. Nieto Y, Shpall EJ. High-dose chemotherapy for high-risk primary and metastatic breast cancer: is another look warranted? Curr Opin Oncol. Mar 2009; 21(2):150-7. PMID 19532017
17. Berry DA, Ueno NT, Johnson MM, et al. High-dose chemotherapy with autologous stem-cell support as adjuvant therapy in breast cancer: overview of 15 randomized trials. J. Clin Oncol. Aug 20 2011; 29(24):3214-23. PMID 21768471
18. Wang J, Zhang Q, Zhou R, et al. High-dose chemotherapy followed by autologous stem-cell transplantation as a first-line therapy for high-risk primary breast cancer: a meta-analysis. PLoS One. 2012; 7(3):e33388. PMID 22428041
19. Martino M, Ballestrero A, Zambelli A, et al. Long-term survival in patients with metastatic breast cancer receiving intensified chemotherapy and stem-cell rescue: data from the Italian registry. Bone Marrow Transplant. Mar 2013; 48(3):414-8. PMID 22863724
20. Pedrazzoli P, Martinelli G, Gianni AM, et al. Adjuvant High-Dose Chemotherapy with Autologous Hematopoietic Stem-cell Support For1183 High-Risk Primary Breast Cancer: Results From The Italian National Registry. Biol Blood Marrow Transplant. Apr 2013; 20(4):501-6. PMID 24374214
21. Kroger N, Frick M, Gluz, O, et al. Randomized trial of single compared with tandem high-dose chemotherapy followed by autologous stem-cell transplantation in patients with chemotherapy-sensitive metastatic breast cancer. J Clin Oncol. Aug 20 2006; 24(24):1919-26. PMID 16921043
22. Schmid P, Schippinge W, Nitsch T, et al. Up-front tandem high-dose chemotherapy compared with standard chemotherapy with doxorubicin and paclitaxel in metastatic breast cancer: results of a randomized trial. J Clin Oncol. Jan 20 2005; 23(3):432-40. PMID 15659490
23. Carella AN, Bregni M. Current role of allogeneic stem-cell transplantation in breast cancer. Ann Oncol. Oct 2007; 18(10):1591-3. PMID 17846023
24. Ueno NT, Rizzo JD, Demirer T, et al. Allogeneic hematopoietic cell transplantation for metastatic breast cancer. Bone Marrow Transplant. Mar 2008; 41(6):537-45. PMID 18084340
25. Fleskens AJ, Lalisang RI, Bos GM, et al. HLA-matched allo-SCT after reduced intensity conditioning with fludarabine/CY in patients with metastatic breast cancer. Bone Marrow Transplant. Mar 2010; 45(3):464-7. PMID 19633692
26. Food and Drug Administration (FDA). Tissue and Tissue Products. Available at http://www.fda.gov> (accessed September 22, 2015).
27. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Breast Cancer V.2.2017 – April 6, 2017. Available at <http://www.nccn.org> (accessed June 16, 2017).
28. Hematopoietic Stem-Cell Transplantation for Breast Cancer. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2015 February) Therapy 8.01.27 (Archived).
Policy History:
|Reviewed. No changes.
|Document updated with literature review. Coverage unchanged.
|Reviewed. No changes.
|Document updated with literature review. Coverage language modified, without change to coverage position. CPT/HCPCS code(s) updated. Title changed from: Stem-Cell Transplant for Breast Cancer.
|Document updated with literature review. The following was added: 1) Donor leukocyte infusion and hematopoietic progenitor cell boost are considered experimental, investigational and unproven; and 2) Any related services for the treatment of breast cancer, such as short tandem repeat (STR) markers, are considered experimental, investigational and unproven. Otherwise, coverage unchanged. Description and Rationale significantly revised.
|New medical document originating from: SUR703.017, Peripheral/Bone Marrow Stem-cell Transplantation (PSCT/BMT) for Non-Malignancies; SUR703.018, Peripheral/Bone Marrow Stem-cell Transplantation (PSCT/BMT) for Malignancies; SUR703.022, Cord Blood as a Source of Stem-cells (CBSC); SUR703.023, Donor Leukocyte Infusion (DLI); and SUR703.024, Tandem/Triple High-Dose Chemoradiotherapy with Stem-cell Support for Malignancies. Stem-cell transplant remains experimental, investigational and unproved when used to treat breast cancer. [NOTE: A link to the medical policies with the following titles can be found at the end of the medical policy SUR703.002, Stem-Cell Reinfusion or Transplantation Following Chemotherapy (General Donor and Recipient Information): Peripheral/Bone Marrow Stem-cell Transplantation (PSCT/BMT) for Non-Malignancies; Peripheral/Bone Marrow Stem-cell Transplantation (PSCT/BMT) for Malignancies; Cord Blood as a Source of Stem-cells; Donor Leukocyte Infusion (DLI); and Tandem/Triple High-Dose Chemoradiotherapy with Stem-cell Support for Malignancies.
Archived Document(s):
|Effective Date:
|End Date:
|Hematopoietic Stem-Cell Transplantation for Breast Cancer
|Hematopoietic Stem-Cell Transplantation for Breast Cancer
|Hematopoietic Stem-Cell Transplantation for Breast Cancer
|Hematopoietic Stem-Cell Transplantation for Breast Cancer
|Stem-Cell Transplant for Breast Cancer
|Stem-Cell Transplant for Breast Cancer


text:
Buy what you love!
?????oh….but I really like it!
I see it everyday….it's not easy to see that when we try something on…and we truly love it and it fits beautifully.…we should not stress about the Price. Now I know… the "b" word…you know…budget! No doubt, we are all there…looking for the best deals, getting the most for your hard earned cash.
But look at your closet, at your home….the things that you enjoy the most, could be the purchases that cost you the most. Now…I'm not saying to break the bank, but rather than just ruling something out because of the price…consider if it will be a quality purchase. Is it something that will bring you joy? More importantly…is it something that you will wear often? If so…that means getting the most for your dollars. It's something that you will look forward to finding in your closet, rather than those discount items that only lasted a couple of wearings.
Fashion Rule: If it fits well, and you love it….don't stress over the dollar amount. More than likely, you find that you closet will fill with items that you love and look forward to wearing.


text:
- Details
- Specs
- Reviews
- What's Included
Increase the efficiency of your current sprinkler system and eliminate hand watering in your small garden, planter beds, and potted plants. This conversion kit connects directly to your existing system or a water faucet to extend watering areas as needed. The kit is equipped with a nine-outlet manifold which delivers 25 PSI of water pressure to each outlet. Twenty-five 8-stream spray spikes allow for flexibility of placement so you can be sure water is delivered exactly where it is needed. With full control over where the water goes, you'll avoid wasting water and ensure healthier plants.
This product is also available for large areas, sold separately.
Specifications Manufacturer ConservCo Manufacturer Product No. ME-8SS-SCK UPC 732185002844
- 1x - 9-outlet manifold
- 1x - 100 feet of distribution line
- 25x - 8-stream spray spikes
- 1x - Owner's Manual
- 1x - 9-outlet manifold


text:
Having a bucket list seems to be the thing to do as you get older. Most of my friends have one and they are slowly working their way through everything they must do before they take that last ride into the sky or to the caverns of the earth. I have a list of things to do before I check-in to the departure lounge but my bucket has a hole in it. Occasionally new things are added to the list but they fall through the hole and I forget what they are.
Most of the things on my list have been suggested by other people who have their own ideas of what I should do and when I should go to the departure lounge. Some of the suggestions were good and I have followed them. Twenty years ago my oncologist suggested I start drinking a better quality red wine. I didn't ask him to clarify what he meant because I didn't want to hear the answer, but I followed his advice. He also told me that people who drink alcohol are more tolerant to chemotherapy than non-drinkers and I proved his theory. It had something to do with the liver function. My lawyer suggested I spend all of my money before my final flight to avoid disputes among my children over the equity of their inheritance. Drinking better quality red wine has helped achieve my lawyer's advice. The problem is I am not an actuary or a prophet so I don't know how much red wine to store for future consumption and I don't want my children to fight over the old wine. The bank has suggested I take out a higher limit credit card and the real estate guy suggested I have my house valued ready to sell. The insurance company has suggested I increase the coverage of my assets and the local car dealer advised me I should upgrade my car before it is too late. My broker advised now is the time to take advantage of the bearish market and buy more equities, and the government has warned me that there will be tough times ahead for older people so I should save. Most of the advice has come from people who have some stake in the outcome but I am not someone who is easily rushed into making a financial decision unless I am the beneficiary.
I have lived by a simple philosophy of when you are young mix with older people and when you are old mix with younger people. So I am taking my advice now from my grandchildren who don't know anything about wine, insurance or equity markets. They don't want me to sell the house or upgrade the car. Both are just fine with them. They do know about credit cards because they see their parents use them. But they don't understand yet that there should be money in the bank to cover them or where money comes from, only where it goes. They don't ask me for anything because they know I would say: "go talk to your parents". Nor do they want me to go to the departure lounge yet because I am a source of independent advice, a standby driver, confidant and a story teller about the good old days. When they ask me a difficult question and I am lost for an answer I change the subject and tell them about the good old days and search through my vast collection of photographs to prove the point. I can't help them with their schoolwork but I remember the good old days. When I want some help with my iPhone, iPad, computer or anything else electronic I go to them for advice, sometimes even assistance. There isn't much point in asking my older friends. The fourteen year old is a wizard with X-Box, Satnav and anything else electronic in the car. The twelve year old is a computer whiz, creative, artistic and great at making videos. She is my creative and computer adviser. The seven year old is a whiz with electronic games and anything related to recording television programs. He has a wisdom way beyond his years. If I ask them what should be on my list of things to do they reply: "What would you like to do? (or) Do something you want to do!" They don't tell me where to go, or when, and won't hear of any talk about the departure lounge. While I would like to solicit advice and help from a wider range of young people the other grandchildren are too far away or too young to understand. So my current advisory panel is limited to three. I would happily expand it if the other grandchildren were close by.
It is nice to talk to positive young people because they don't talk about their current or recent illnesses, medication and supplements, only their achievements, ambitions and the latest electronic gadgets and games. They are focused on the sunlight not the darkness. Going to lunch with them is a simple and quick exercise. There is no long discussion over calories, diets, what we can and cannot eat and drink, and whether we should order white or red wine to match the food. It is poached eggs on toast, a muffin, pretzel, vanilla ice cream, chocolate milk and we are out of there. What the grandchildren don't know but some of my older friends do is that I have long had a barrel list which I find larger and more positive than a bucket list especially one with a hole in it. For many years now I have been quietly visiting the major wine growing areas of the world under the guise of a vacation. There I explore the wonders of winemaking and drinking with people of similar tastes who take a simple approach to sampling red wine. Drink it, don't sip it and spit it out. And I have learned how to read a large hard cover book with one hand while holding a glass of wine with the other, a useful skill for traveling between vineyards. And when asked which is my favorite wine I give a generic answer: "red". But new vineyards and wine makers are springing up around the world, faster than I can get to them. This year I visited the grape growing and wine making areas of Valais, Ticino, Etyek-Buda, Neszmely, Moravia and Saxony; and three great wine stores in the US on Second Avenue, New York City, and Hyde Park, NY and Winchester, MA. There are so many more to visit and so little time. Richard Carlson, author of "Don't Sweat the Small Stuff…and it is all small stuff" (1997) wrote "When you die, Your "In Basket" Won't be Empty. I worry about my barrel being full of unfulfilled dreams and wineries I haven't seen, and the departure lounge not having a better quality red wine.
Ken Peacock
Ken Peacock, a former senior Australian executive of a mining company, first visited China in 1972 at the end of the Cultural Revolution and before diplomatic recognition by the Australian and US Governments. This was the first of many visits to China during the 1970s and 1980s. In 1978, he traveled throughout China with a trade delegation and revisited Shanghai where he stayed at the Shanghai Mansions Hotel and discovered the "Last Bottle of Gin in China".


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Sanderson told Travis there were many animals around with a sickness called hydrophobia
"How Can you tell if they got it?" asked Travis.
"They go crazy before they die. Watch for foam at the mouth. If some animal comes at
you, shoot quick. If it gets one bite at you, you'll get the sickness. And then no one can
help you."
Travis didn't have much chance to worry about hydrophobia, for it was hog-marking time.
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The Veloster lands somewhere between compacts and hot hatches such as the Mazda3 and the larger Volkswagen Golf, MINI Cooper and Volkswagen Beetle. The Veloster stands out by offering cavernous interior space for both cargo and passengers. Efficiency too, will attract buyers, particularly with the sprightly 1.6L turbo, which manages sub-6 second 0-60 mph acceleration times as well as excellent fuel economy, achieving over 30 mpg on the highway in Turbo trim.
Compare the 2019 Hyundai Veloster against similar models
The 2019 Hyundai Veloster moves into its first new generation since its introduction. Most everything has been updated and revised providing an aggressive twist on exterior styling. The waterfall front grille is larger and bolder, the headlights are sleeker and better accent the re-worked front fascia. LED running lights are now standard as well as a larger rear diffuser and raked rear roofline to add a more pronounced shape to the back end of the vehicle. The interior is updated around trim-specific color and material schemes and includes an optional 8-inch touchscreen-based infotainment system. A multi-link independent rear suspension replaces the outgoing model's torsion beam setup, promoting sporty and responsive handling.
A vehicle's warranty can significant impact your maintenance costs after you drive off the dealer's lot, and it's important to understand the different parts. Typically, a new car warranty includes a Basic warranty, which covers everything except the wear items such as brakes and tires; and a Drivetrain warranty, that covers all the parts that make the car move, such as the engine and transmission
Below are pictures of the 2019 Hyundai Veloster. Select the picture you want to view below
Below are the available colors for the 2019 Hyundai Veloster. Select the color to see a close-up view.
The 2019 Hyundai Veloster is no sporty-hatch carbon copy. Unlike any compact car on the road, the asymmetrical Veloster boasts two doors on the passenger side, but only the front door on the driver's side.
Introduced as a 2012 model, the Veloster skipped the 2018 model year. The returned version is nearly identical in form, but slightly bigger. The 2.0-liter base engine is more powerful this time around, gaining 15 horsepower. LED headlights and taillights have been added. Hyundai also has launched a new Veloster N edition, with higher power and a manual gearbox.
In addition to the new N model, Velosters come in five trim levels: 2.0 (base model), 2.0 Premium, turbocharged R-Spec, Turbo, and Turbo Ultimate.
Hyundai has largely carried over the Veloster's two standard powertrains, but added power to one of them. The base 2.0-liter 4-cylinder is now rated at 147 horsepower and 132 pound-feet of torque, versus 132 hp and 120 pound-feet in the 2017 model.
The 1.6-liter turbo 4-cylinder engine is a total carryover, again issuing 201 horsepower and 195 pound-feet of torque. Those figures match every other Hyundai vehicle that offers the turbo-4 engine.
Both engines mate with a standard 6-speed manual gearbox. A 6-speed automatic transmission is optional for the base engine, but the turbo-4 is offered with a 7-speed dual-clutch transmission.
Drive modes toggle between Normal, to Sport, and Smart on automatic-transmission versions, but only Normal and Sport on manual-shift models. These modes alter steering heft, throttle progression, and shift timing.
In the new Veloster N, the 2.0-liter turbo-4 develops 275 horsepower and 260 pound-feet, paired only with a 6-speed manual transmission. An electronically-controlled suspension is installed, with multiple track-tuned driving modes.
Neither of the two rating agencies has crash-tested the current Veloster yet. Every 2019 Veloster gets forward-collision warnings with automatic emergency braking, plus active lane control.
Upper models are equipped with blind-spot monitors, but the base model relies on blind-spot mirrors. Adaptive cruise control and pedestrian detection are in the Ultimate Turbo.
Prices do not include $920 destination charge.
2.0 Base ($18,500 with manual, $19,500 with 6-speed automatic) includes the 2.0-liter engine, cruise control, Bluetooth, 7.0-inch touchscreen display, Apple CarPlay and Android Auto, capability, 17-inch alloy wheels, and automatic emergency braking.
2.0 Premium ($22,750) comes with a 6-speed automatic transmission, 18-inch wheels, blind-spot monitors, keyless ignition, wireless smartphone charging, an 8.0-inch infotainment touchscreen, Infinity 8-speaker audio, a sunroof, heated front seats, paddle shifters, and cloth/synthetic leather upholstery.
Turbo R-Spec manual ($22,900) holds the 1.6-liter turbo-4 and 6-speed manual gearbox. Standard are Michelin Pilot Sport 4 summer tires on 18-inch wheels, LED headlights and taillights, sport-tuned suspension/steering and exhaust, and alloy pedals.
Turbo DCT ($25,400) gets the 1.6-liter turbo and dual-clutch transmission, as well as heated front seats, sunroof, blind-spot monitors, leather/cloth upholstery, and automatic climate control.
Turbo Ultimate ($26,650 with manual, $28,150 with dual-clutch) includes the 1.6-liter turbo, leather upholstery, black roof, navigation, wireless smartphone charging, a head-up display, and pedestrian detection for its automatic emergency braking.
Turbo N 2.0 manual ($26,900) upgrades to a 275-horsepower 2.0-liter turbo 4-cylinder, with 6-speed manual shift. Standard features include 18-inch wheels, cloth sport seats with blue stitching, sport instrument cluster, and electronic suspension. A $2,100 Performance Package adds a limited-slip differential and 19-inch Pirelli tires.
Defiantly offbeat in its original form, the reworked Veloster has been expertly refined, for a more cohesive appearance. Yet its unique shape and configuration remain, topped by a sporty roofline.
Designers have done a good job blending the prominent grille, deep front fascia, and slimmed-down headlights to correlate with the other Hyundai models. Windshield pillars were pushed rearward, stretching out the hood. Wheel arches boast flagrant flares.
A new diffuser flanks the center-positioned exhaust pipes: one for standard models, but twin pipes for the Veloster Turbo. A contrasting roof is available for the Turbo. The new Veloster N earns some distinct styling touches including specific front/rear fascias and side air dams.
Inspired by the recently-launched Kona crossover, the Veloster's cabin is highlighted by a big touchscreen above the center stack. Piano black trim and hard plastic elements, while abundant, are neatly executed.
Though seemingly clever, the audacious door configuration doesn't add much utility. Interior space has barely changed, but quality of materials reaches well past the prior Veloster.
Front seats have better padding now, with much thicker upper-back bolstering. Base models get cloth seats, but some Turbos feature a grippy cloth/leather combination.
Two medium-size adults fit in back, at least for occasional jaunts. All told, reaching the Veloster's back seat isn't much easier than entering a similar-size two-door hatchback or coupe. Once there, a 6-foot passenger can expect to slouch a bit, splaying knees outward to fit.
Although the cabin remains rather narrow, headroom in sunroof-equipped models is just sufficient enough to keep tall occupants' heads from touching the roof. Power seats are no longer offered.
Climate and audio controls are logically arranged. Working with a well-executed infotainment system, either a 7.0- or 8.0-inch touchscreen sits above the attractive center stack.
Cargo space totals 19.9 cubic feet behind the rear seat. Liftover is high, but the hatch release is cleverly mounted in the rear wiper's housing.
A stiffened body structure has improved Veloster handling capabilities. A new multi-link suspension helps make it more predicable. Quick steering isn't quite as precise as some drivers might desire, but it's generally fine, apart from exhibiting some on-center wander.
Ride quality is on the firm side, short on compliance. Mid-corner bumps and pavement flaws no longer upset the Veloster's equilibrium. Even Turbo models, if wearing all-season tires, ride softly enough to ensure adequate comfort. Still, some skittering is likely when traversing swift, tight corners.
The base engine has not yet been test-driven, but the 201-horsepower Turbo promises a sizable helping of joy. Energetic and responsive, the turbo-4s feel strong and quick, helped by vehicle weight of less than 3,000 pounds. In manual-gearbox Turbos, the shift level yields a satisfying snick as it moves between ratios. Hyundai's dual-clutch transmission shifts cleanly at mid-range speeds, but can become touchy at urban speeds.
Turbos get amplified, synthetic engine sounds pumped into the cabin, but this feature can be toned down or shut off. Otherwise, thicker door panels and more sound deadening help keep unwanted noise under control.
Ready to invite comparison with Honda's striking Civic Type R, the new 275-horsepower Veloster N boasts a firmer suspension, limited-slip front differential, and special steering tuning.
Fuel economy is reasonably good. With manual shift, base-engine versions are EPA-rated at 25/33 mpg City/Highway, or 28 mpg Combined. The 6-speed automatic raises the estimate to 27/34/30 mpg. The manual-shift Veloster Turbo is EPA-rated at 26/33 mpg City/Highway, or 29 mpg Combined, and 28/34/30 mpg with the dual-clutch transmission.
Not only is the 2019 Hyundai Veloster better looking, it's a lot more refined for a higher-quality feel. Handling has improved, but the door configuration seems like more of a gimmick than a practical necessity. More than before, the sporty Veloster is a compelling rival to various performance-ready models from Honda and Volkswagen.
Driving impressions by Martin Padgett, The Car Connection. James M. Flammang contributed to this report.
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FTZ Actions on Upholstery Fabric, Vessel, Industrial Sensor, Apparel Facilities
Upholstery Fabrics. The Foreign-Trade Zones Board has approved a limited expansion of production authority under zone procedures at the Klaussner Furniture Industries Inc. facilities within subzone 230D in Asheboro and Candor, N.C. This approval extends KFI's authority to conduct cut-and-sew activity using certain foreign micro-denier suede upholstery fabrics to produce upholstered furniture and related parts (upholstery cover sets). This approval is subject to a restriction requiring that foreign status upholstery leather, including hides classified under HTSUS subheadings 4107.11, 4107.92 and 4107.99, be admitted to the subzone in privileged foreign status.
Oceangoing Vessels. The FTZ Board has authorized production under zone procedures at the Thoma-Sea Marine Constructors LLC facilities in Houma, La., which are used for the construction and repair of oceangoing vessels. This approval is subject to the following special conditions: (1) any foreign steel mill products admitted to the zone for this activity, including plate, angles, shapes, channels, rolled steel stock, bars, pipes and tubes, not incorporated into merchandise otherwise classified, and that is used in manufacturing, will be subject to full customs duties in accordance with applicable law unless the FTZ Board determines that the same item is not then being produced by a domestic steel mill; and (2) Thoma-Sea must annually advise the FTZ Board as to significant new contracts with appropriate information concerning foreign purchases otherwise dutiable so that the FTZ Board may consider whether any foreign dutiable items are being imported for manufacturing in the zone primarily because of FTZ procedures and whether the FTZ Board should consider requiring customs duties to be paid on such items.
Industrial Sensors. The Greater Metropolitan Area Foreign Trade Zone Commission, grantee of FTZ 119, has submitted a notification of proposed production activity at the SICK Inc. facility in Savage, Minn. SICK already has authority to produce photo-electronic industrial automation sensors within subzone 119G and the current request would add new finished products (encoders, zone control sensors, proximity sensors, integrated optical readers, data process monitoring/reporting systems) and certain foreign components and materials to the scope of authority. Comments on this notification are due no later than July 20.
Apparel. The Dothan-Houston County Foreign Trade Zone Inc., grantee of FTZ 233, is requesting subzone status for the Next Level Apparel facility in Ashford, Ala. No authorization for production activity has been requested at this time. Comments on this request are due no later than July 20.