Transplant Services. Transplant services are limited to AvMed’s In-Network Center of Excellence facilities located within the State of Florida. Transportation costs for a companion to accompany the Member (or two companions when the patient is a minor) are covered only if the Member has to travel greater than a 50-mile radius to receive the transplant, and are limited to $200 per day up to a $10,000 lifetime maximum.
Transplant Services. Expenses for the following are excluded:
a. transplant procedures excluded under this Contract (e.g., Experimental or Investigational transplant procedures);
b. transplant procedures involving the transplantation or implantation of any non-human organ or tissue;
c. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered by XxXxx;
d. transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ;
e. any organ, tissue, marrow, or stem cells which is/are sold rather than donated;
f. any Bone Marrow Transplant, as defined herein, which is not specifically listed in Rule 59B-12.001, Florida Administrative Code, or any successor or similar rule or covered by Medicare pursuant to a national coverage decision made by CMS as evidenced in the most recently published Medicare National Coverage Determinations Manual;
g. any service in connection with the identification of a donor from a local, state or national listing, except in the case of a Bone Marrow Transplant;
h. any non-medical costs, including temporary lodging or transportation costs for you or your family to and from the approved facility, except as described in Part X.
Transplant Services. Benefits are available for tissue and kidney transplants and special transplants. Benefits are available for facility and professional services provided in connection with human tissue and kidney transplants when you are the transplant recipient. Benefits include services incident to obtaining the human transplant material from a living donor or a tissue/organ transplant bank. Benefits are available for special transplants only if: • The procedure is performed at a special transplant facility contracting with Blue Shield, or if you access this Benefit outside of California, the procedure is performed at a transplant facility designated by Blue Shield; and • You are the recipient of the transplant. Special transplants are: • Human heart transplants; • Human lung transplants; • Human heart and lung transplants in combination; • Human liver transplants; • Human kidney and pancreas transplants in combination; • Human bone marrow transplants, including autologous bone marrow transplantation (ABMT) or autologous peripheral stem cell transplantation used to support high-dose chemotherapy when such treatment is Medically Necessary and is not Experimental or Investigational; • Pediatric human small bowel transplants; and • Pediatric and adult human small bowel and liver transplants in combination.
Transplant Services. Expenses for the following are excluded:
a. transplant procedures excluded under this Contract (e.g., Experimental or Investigational transplant procedures);
b. transplant procedures involving the transplantation or implantation of any non-human organ or tissue;
c. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered by XxXxx;
d. transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ;
e. any organ, tissue, marrow, or stem cells which is/are sold rather than donated;
f. any Bone Marrow Transplant, as defined herein, which is not specifically listed in Rule 59B-12.001, Florida Administrative Code, or any successor or similar rule or covered by Medicare pursuant to a national coverage decision made by CMS as evidenced in the most recently published Medicare National Coverage Determinations Manual;
g. any service in connection with the identification of a donor from a local, state or national listing, except in the case of a Bone Marrow Transplant;
h. any non-medical costs, including temporary lodging or transportation costs for you or your family to and from the approved facility, except as described in Section 10.19;
i. any artificial heart, mechanical device, or ventricular assist device (VAD) that replaces either the atrium or the ventricle;
j. collection and storage costs associated with the banking of umbilical cord blood;
k. transplant services and procedures provided by or at facilities that are not AvMed In-Network Center of Excellence facilities located within the State of Florida.
Transplant Services. Eligibility for Covered Services related to human organ, bone and tissue transplant are as follows. When the Member is the recipient of transplanted human organs, marrow, or tissues, benefits are provided for all Covered Services. Covered Services for Inpatient and Outpatient Care related to the transplant include procedures which are generally accepted as not Experimental/Investigational Services by medical organizations of national reputation. These organizations are recognized by the HMO as having special expertise in the area of medical practice involving transplant procedures. Benefits are also provided for those services which are directly and specifically related to the Member’s covered transplant. This includes services for the examination of such transplanted organs, marrow, or tissue and the processing of blood provided to the Member. The determination of Medical Necessity for transplants will take into account the proposed procedure's suitability for the potential recipient and the availability of an appropriate facility for performing the procedure. Eligibility for Covered Services related to human organ, bone and tissue transplant are as follows. If a human organ or tissue transplant is provided from a donor to a human transplant recipient:
1. When both the recipient and the donor are Members, each is entitled to the benefits of this plan.
2. When only the recipient is a Member, both the donor and the recipient are entitled to the Benefits of this Agreement. However, donor Benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage or any government program.
3. When only the donor is a Member, the donor is entitled to the Benefits of this Agreement, subject to following additional limitations:
a. The Benefits are limited to only those not provided or available to the donor from any other source in accordance with the terms of this Agreement; and
b. No Benefits will be provided to the non-Member transplant recipient.
4. If any organ or tissue is sold rather than donated to the Member recipient, no Benefits will be payable for the purchase price of such organ or tissue; however, other costs related to evaluation and procurement are covered. Benefits for a covered transplant procedure shall include coverage for the medical expenses of a live donor to the extent that those medical expenses are not covered by another program. Covered Services of a do...
Transplant Services. Subject to the provisions of this Agreement, benefits will be provided for Covered Services furnished by a Hospital which are directly and specifically related to transplantation of organs, bones, tissue or blood stem cells. If a human organ, bone, tissue or blood stem cell transplant is provided from a living donor to a human transplant recipient:
1. When both the recipient and the donor are Members, each is entitled to the benefits of this Agreement;
2. When only the recipient is a Member, both the donor and the recipient are entitled to the benefits of this Agreement subject to the following additional limitations:
a. The donor benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage, or other Blue Cross or Blue Shield coverage or any government program, and
b. Benefits provided to the donor will be charged against the recipient’s coverage under this Agreement to the extent that benefits remain and are available under this Agreement after benefits for the recipient’s own expenses have been paid;
3. When only the donor is a Member, the donor is entitled to the benefits of this Agreement, subject to the following additional limitations:
a. The benefits are limited to only those not provided or available to the donor from any other source in accordance with the terms of this Agreement, and
b. No benefits will be provided to the non-Member transplant recipient;
4. If any organ, tissue or blood stem cell is sold rather than donated to the Member recipient, no benefits will be payable for the purchase price of such organ, tissue or blood stem cell; however, other costs related to evaluation and procurement are covered up to the Member recipient’s Agreement limit. Y. VISION CARE SERVICES Benefits are provided for Members every twelve (12) consecutive months for the following when rendered by a Vision Provider who is a Network Provider:
a. one (1) comprehensive eye examination (including dilation as professionally indicated);
b. one (1) pair of single vision, bifocal, trifocal or lenticular lenses (including glass, plastic or oversized lenses); and
c. one (1) pair of frames from a selection designated by the Plan. Coverage for Pediatric Vision Care Services terminates at the end of the month in which the Member reaches age nineteen (19). Benefits provided under this Subsection are not subject to the provisions of Subsection F. COORDINATION OF BENEFITS of SECTI...
Transplant Services. Provision of transplant services is limited to Center of Excellence facilities located within the State of Florida, with whom XxXxx has contracted to provide transplant services as described in this Contract. Transportation costs for a companion to accompany the Member (or two companions when the patient is a minor) are covered only if the Member has to travel greater than a 50-mile radius to receive the transplant, and are limited to $200 per day up to a $10,000 lifetime maximum.
Transplant Services. Expenses for the following are excluded:
a. transplant procedures excluded under this Contract (e.g., Experimental or Investigational transplant procedures);
b. transplant procedures involving the transplantation or implantation of any non-human organ or tissue;
c. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered by XxXxx;
d. transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ;
e. any organ, tissue, marrow, or stem cells which is/are sold rather than donated;
f. any Bone Marrow Transplant, as defined herein, which is not specifically listed in Rule 59B-12.001, to a national coverage decision made by CMS as evidenced in the most recently published Medicare National Coverage Determinations Manual;
g. any service in connection with the identification of a donor from a local, state or national listing, except in the case of a Bone Marrow Transplant;
h. any non-medical costs, including temporary lodging or transportation costs for you or your family to and from the approved facility, except as described Part X.
Transplant Services. For those transplant (bone marrow/stem cell and solid organ) services for which PARTICIPATING MEDICAL GROUP is financially responsible (i.e., professional component), PARTICIPATING MEDICAL GROUP shall pay for services at the applicable rate negotiated by BLUE CROSS for professional transplant services or at the rate negotiated by PARTICIPATING MEDICAL GROUP. If such payment has been made directly by BLUE CROSS to the provider, PARTICIPATING MEDICAL GROUP shall remit payment to BLUE CROSS within forty-five (45) days of BLUE CROSS’ written request or BLUE CROSS may adjust subsequent Capitation payments to offset such payment amount.
Transplant Services. The benefit package includes transplantation services. The following transplants are covered in the benefit package: heart transplants, lung transplants, heart-lung transplants, liver transplants, kidney transplants, autologous bone marrow transplants, allegoric bone marrow transplants and corneal transplants, as detailed in MAD Program Manual Section MAD-764, TRANSPLANT SERVICES, Section MAD-765, EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES, TECHNOLOGIES, OR NON-DRUG THERAPIES.
