Common use of Transplants Clause in Contracts

Transplants. Organ, including artificial organs when medically approved by your doctor and in accordance with the manufacturer’s recommendations, bone marrow and stem cell transplants are covered when clinical coverage criteria are met and the transplant is approved by us. Pre-authorization is required for transplant services. Services directly related to organ transplants must be coordinated by your In-Network Provider. A proposed transplant will not be covered if considered Experimental or Investigational for the Member’s condition. Pre-Authorization approval for transplants is based on these criteria: • A written recommendation with supporting documentation received from your Provider; • The request for the transplant is based on Medical Necessity; • The requested procedure and associated protocol is not considered an Experimental or Investigational treatment for your condition; • The procedure is performed at a facility, and by a Provider, approved by us; and • Upon evaluation, you are accepted into the approved facility’s transplant program and you comply with all program requirements.