Transplants. This plan covers transplant services when they are provided at an approved transplant center. An approved transplant center is a hospital or other provider that Premera has approved for solid organ transplants or bone marrow or stem cell reinfusion. Please call us as soon as you learn you need a transplant. This plan only covers transplant procedures that are not considered Experimental or Investigational for Your condition. Solid organ transplants and bone marrow/stem cell reinfusion procedures must meet coverage criteria. We review the medical reasons for the transplant, how effective the procedure is and possible medical alternatives. Artificial organ transplants are covered based on your doctor’s medical guidelines and the manufacturer recommendations. These are the types of transplants and reinfusion procedures that meet our medical policy criteria for coverage: • Heart • Heart/double lung • Single lung • Double lung • Liver • Kidney • Pancreas • Pancreas with kidney • Bone marrow (autologous and allogeneic) • Stem cell (autologous and allogeneic) Under this benefit, transplant does not include cornea transplant or skin grafts. It also does not include transplants of blood or blood derivatives (except bone marrow or stem cells). These procedures are covered the same way as other covered surgical procedures.
Transplants. This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Human Solid Organ transplant benefits are Covered for: • Kidney • Liver • Pancreas • Intestine • Heart • Lung • multi-visceral (3 or more abdominal Organs) • simultaneous multi-Organ transplants – unless investigational • pancreas islet cell infusion • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization.
Transplants. 1. Health care services for organ and tissue transplants, except those described under Transplantation Services in Section 1: Covered Health Care Services.
2. Health care services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. (Donor costs that are directly related to organ removal are payable for a transplant through the organ recipient's Benefits under this Policy.)
3. Health care services for transplants involving animal organs.
4. Transplant services not received from a Designated Provider. This exclusion does not apply to cornea transplants.
Transplants. Follow up care provided on or after the Member’s Transition that is billed outside the Global Charges, will be the responsibility of the New MCO.
Transplants. If the following criteria are met, we cover stem cell rescue and transplants of organs, tissue or bone marrow: 1. You satisfy all medical criteria developed by Medical Group and by the facility providing the transplant; 2. The facility is certified by Medicare; and 3. A Plan Provider provides a written referral for care at the facility. After the referral to a transplant facility, the following applies: 1. Unless otherwise authorized by Medical Group, transplants are covered only in our Service Area.
Transplants. Stem cell, kidney, liver, heart, lung, pancreas, small bowel, or any combination are covered. Includes services related to organ procurement and donor expenses if not covered under another plan. Member must contact medical plan for arrangements.
Transplants. Transplants which are non-experimental or non-investigational are a Covered Benefit. Covered transplants must be ordered by the Member’s PCP and Participating Specialist Physician and pre-authorized by HMO's Medical Director. The transplant must be performed at Hospitals specifically approved and designated by HMO to perform these procedures. A transplant is non-experimental and non- investigational hereunder when HMO has determined, in its sole discretion, that the Medical Community has generally accepted the procedure as appropriate treatment for the specific condition of the Member. Coverage for a transplant where a Member is the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.
Transplants. The Health Plan shall ensure that all decisions to deny a service authorization request, or limit a service in amount, duration, or scope that is less than requested, are made by health care professionals who have the appropriate clinical expertise in treating the enrollee’s condition or disease (see 42 CFR 438.210(b)(3)).
Transplants. The Health Plan shall provide medically necessary transplants and related services as outlined in the chart below for applicable Reform and non-Reform populations.
1. For transplant services specified with one (1) asterisk, Reform capitated Health Plans are paid by the Agency through kick payments. See Attachment I and Attachment II, Section XIII, Method of Payment, for payment details.
2. Transplant services specified with two (2) asterisks, as well as pre- and post-transplant follow-up care, are covered through fee-for-service Medicaid and not by the Health Plan. If at the conclusion of the transplant evaluation, the enrollee is listed with the United Network for Organ Sharing (UNOS) as a level 1A, 1B, or 2 candidate for a heart or lung transplant, or with a Model End Stage Liver Disease (MELD) score of 11-25 for a liver transplant, then the Health Plan must submit a copy of the UNOS form to BMHC with a request to disenroll the member from the Health Plan. The recipient cannot re-enroll with the Health Plan until at least one (1) year post transplant. This re-enrollment is not automatic.
3. Transplant evaluation services are transplant-related services up to placement on the UNOS list. Evaluation Health Plan Health Plan Health Plan Health Plan Bone Marrow Health Plan Health Plan Health Plan Health Plan Cornea Health Plan Health Plan Health Plan Health Plan Heart Health Plan* Health Plan* Medicaid** Medicaid** Intestinal/ Multivisceral Medicaid** Medicaid** Medicaid** Medicaid** Kidney Health Plan Health Plan Health Plan Health Plan Liver Health Plan* Health Plan* Medicaid** Medicaid** Back to 10-Q Exhibit 10.3 Lung Health Plan* Health Plan* Medicaid** Medicaid** Pancreas Health Plan Health Plan Health Plan Health Plan Pre- and Post-Transplant Care, including Transplants Not Covered by Medicaid Health Plan Health Plan Health Plan(except heart, lung, or liver) Health Plan(except heart, lung, or liver) Other Transplants Not Covered by Medicaid Not Covered Not Covered Not Covered Not Covered
14. Attachment II, Core Contract Provisions, Section V, Covered Services, Item H., Coverage Provisions, sub-item 15.h.
Transplants. Health care services for organ and tissue transplants, except those described under Transplantation Services and/or Surgery – Outpatient Services in Section 1: Covered Health Care Services.
