Currentblue cross blue shield - michiganPolicy BCNA

Human organ transplant services

Governs coverage, payment, and billing rules for human organ transplant services for BCN Advantage Medicare members, including facility and provider requirements tied to Original Medicare rules.

Policy Summary

Payerblue cross blue shield - michigan

PolicyHuman organ transplant services

Policy CodePolicy BCNA

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionPerform covered transplants at CMS-approved/certified transplant facilities (or facilities with a Medicare provider agreement) to ensure coverage and payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Original MedicareTransplant types covered

CMS-approvedFacility requirement

CMS 1500/UB-04/837Claim forms

AppliesMember cost sharing

Coverage Criteria for Human Organ Transplants

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Facility and plan: Procedure is covered by Original Medicare and performed at a CMS-approved/certified transplant facility or facility meeting Medicare provider agreement

BCN Advantage follows Original Medicare facility requirements and covers transplants that Original Medicare covers.

Member plan: Member is enrolled in BCN Advantage and the transplant type is covered under Original Medicare

BCN Advantage provides at least the same level of benefits as Original Medicare and may provide enhanced benefits.

Medicare NCD transplant exclusions

Not covered (Original Medicare NCD exclusions):

Autologous stem cell transplant exclusions: Autologous stem cell transplants are not covered for specified conditions including acute leukemia not in remission, chronic granulocytic leukemia, solid tumors other than neuroblastoma, tandem transplantation for multiple myeloma, non-primary AL amyloidosis, and primary AL amyloidosis for beneficiaries age 65 and older

Per Medicare NCD 110.23.

Allogeneic transplant exclusions: Allogeneic stem cell transplants are not covered for multiple myeloma

Per Medicare NCD 110.23.

Per Medicare NCD 110.23, the following stem cell transplant indications are not covered: Autologous stem cell transplant (AuSCT) for acute leukemia not in remission; chronic granulocytic leukemia; solid tumors other than neuroblastoma; tandem transplantation for multiple myeloma; non-primary AL amyloidosis; and primary AL amyloidosis for Medicare beneficiaries age 65 and older. Additionally, allogeneic stem cell transplants are not covered for multiple myeloma. These exclusions apply to BCN Advantage in alignment with Original Medicare.

Billing, Claims and Procedure Codes

Required claim forms and transactionsmixed

CMS 1500, UB-04, 837

Claim forms to bill transplant services

Provider billing and transaction instructionsmixed

NPI	Report National Provider Identifier on all claims

Billing methodmixed

Electronic billing (ANSI ASC X12N 837/835)

Electronic institutional 837/835 for Michigan providers per BCN EDI companion documents

Procedure and billing codesmixed

CPT/HCPCS

Report CPT/HCPCS codes to the highest level of specificity consistent with Original Medicare

Diagnosis codingmixed

Diagnosis codes

Report diagnosis codes to the highest level of specificity

Provider Requirements and Billing Actions

Prior Authorization

Prior Authorization for Covered Transplants

BCN Advantage members do not require prior authorization for covered human organ transplants when the service is performed at a facility that has a Medicare provider agreement and is certified by CMS for the relevant transplant procedure. Members may receive care at facilities outside the Blue Cross network if the facility meets these CMS requirements.

Applies to covered human organ transplants as defined by Original Medicare.
Facility must have a Medicare provider agreement and CMS certification for the specific transplant.

Note

Providers should note that BCN Advantage follows Original Medicare facility requirements for organ transplants. Ensure services are performed in CMS-approved transplant centers when required by Medicare guidance.

Heart, lung, liver, kidney, pancreas, bone marrow/stem cell and other Medicare-covered transplants follow Medicare facility criteria.
Some transplants (e.g., stem cell, corneal) have specific Medicare rules; verify facility and diagnosis restrictions as applicable.

Documentation Required

Claim Documentation and Billing

Report all CPT/HCPCS and ICD-10 diagnosis codes to the highest level of specificity and include the billing provider's NPI on every claim. Bill on the CMS 1500 (02/12), UB-04, or the 837 equivalent and follow BCN Advantage unique billing requirements.

Use electronic billing (ANSI X12N 837/835) where available.
Follow Michigan vs. out-of-state provider billing instructions per BCN Advantage guidance.
Coverage outside Michigan for BCN Advantage HMO members is limited unless BCN Advantage approves out-of-network services in advance.

Billing Rule

Facility Certification Required

Services must be performed in facilities that meet CMS/provider certification requirements; payable locations align with CMS-approved transplant facilities and Original Medicare facility requirements apply.

Verify the facility is listed as a CMS-approved transplant center for the relevant organ/procedure.
Organ acquisition costs for kidney transplants for MA beneficiaries may be managed under FFS per current CMS guidance — confirm payer responsibility for acquisition costs when applicable.

Background

Human organ transplant is the surgical removal of a whole or partial organ from one body to another, or from a donor (living or deceased) to replace a damaged or failing organ. Transplants are considered lifesaving procedures and include organs such as heart, lung, liver, kidney, pancreas, bone marrow/stem cell and cornea. BCN Advantage follows Original Medicare for coverage and facility requirements for these services.

Definitions

Human organ transplant — definition

TermHuman organ transplant

DefinitionSurgical removal of a whole or partial organ from one body to another, or from a donor site on the patient's own body, to replace a damaged or failing organ.

Donor typesLiving or deceased donors

Clinical classificationTypically considered lifesaving procedures (distinct from life‑enhancing tissue transplants)

Facility requirement noteBCN Advantage members may receive care at facilities outside the Blue Cross network if the facility has a Medicare provider agreement and is CMS‑certified for the procedure.

Candidate Eligibility and Organ Types

Candidate organ types

Candidates eligible when meet Original Medicare clinical and facility criteria:

Covered organ types: Heart; heart-lung; lung; lobar lung; liver; bone marrow or stem cell; pancreas; kidney; corneal transplant; simultaneous pancreas-kidney; intestinal (small bowel); multi-visceral; stomach; duodenum; pancreas, liver, intestine and pancreatic tissue; islet cell (covered only in clinical trial)

Listed as covered under Original Medicare and BCN Advantage follows these coverages; facility requirements per Original Medicare apply.

Pre-Transplant Evaluation Requirements

Documentation Required

Complete pre‑transplant evaluation and workup required

Coverage includes all necessary tests, labs, and exams prior to surgery; perform and document the full transplant workup consistent with Medicare and the transplant center’s requirements.

Include necessary preoperative tests, labs and exams as part of the covered workup.
For stem cell transplants (when covered), document mobilization, harvesting, conditioning (high‑dose radiotherapy/chemotherapy) and infusion phases.

Facility and Center Requirements

Billing Rule

Use CMS‑approved transplant centers or Medicare‑certified facilities

Perform transplant procedures only in CMS‑approved transplant centers or facilities that meet Medicare provider agreements and certification—Original Medicare facility requirements apply to all organ transplant procedures.

BCN Advantage follows Original Medicare facility requirements for transplant procedures.
Confirm the facility has a Medicare provider agreement and CMS certification for the specific transplant.

Post-Transplant Follow-up and Organ Procurement

Follow-up care and organ procurement

Coverage statementFollow-up care and organ procurement are included in coverage consistent with Original Medicare.

Included services examplesNecessary tests, labs and exams before surgery; immunosuppressive drugs under certain conditions; follow-up care; procurement of organs.

Facility implicationCoverage follows Original Medicare facility requirements; many transplants must be performed in CMS‑approved transplant centers.

ScopeApplies to organ transplants covered by Original Medicare as listed by Medicare (e.g., heart, lung, liver, kidney, pancreas, bone marrow/stem cell, cornea, intestinal, multi‑visceral, etc.).