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. Covered Transplants 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. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $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.
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. 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. The Health Plan shall provide medically necessary transplants and related services as outlined in the chart below for applicable Reform and non-Reform populations.
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. (e) 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 i. As a general principle, the MCO shall cover the same transplants as covered by Medicare regardless of whether the member is enrolled in Medicare. If the transplant is not covered by Medicare, the MCO shall follow the procedure outlined in Section F., Determining if Services, Procedures, Items and Treatments are Proven and Effective, page 85, to determine coverage.
Transplants. As a general principle, Wisconsin Medicaid does not pay for items that it determines to be experimental in nature.
