Currentblue cross blue shield - michiganPolicy MAPPO 1018

Human organ transplant services

Defines coverage, payment conditions, member cost sharing, and billing instructions for Medicare Plus Blue Group PPO members receiving human organ transplant services; includes alignment with Original Medicare facility requirements and select enhanced benefits for Group PPO plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyHuman organ transplant services

Policy CodePolicy MAPPO 1018

Change TypeOperational and reference updates

Effective Date

Next Review Date

Key ActionPerform covered transplants in CMS-approved transplant centers and follow Medicare facility requirements to ensure payment.

SourceLink

POLICY UPDATE CHANGES

Changed references of State Health Plan MA to State Health Plan Medicare Advantage PPO.

Added cost sharing information for University of Michigan.

Updated Original Medicare section to reflect new information regarding organ acquisition costs for kidney transplants for MA beneficiaries per CMS guidance.

Updated National Coverage Determination reference from 110.8.1 to 110.23.

Original MedicareTransplant procedures covered for Medicare Plus Blue members

1 yearBenefit period duration

Medicare-approvedFacility requirement

MAPPO 1018Policy identifier

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Coverage Criteria

Original Medicare-covered transplants

Covered when consistent with Original Medicare and performed in CMS-approved transplant centers; additional enhanced benefits apply to select Group PPO plans when listed conditions are met.

Original Medicare-aligned coverage: Transplants listed under Original Medicare (heart; heart-lung; lung; liver; lobar lung; 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 [clinical trial only]) are covered when performed in facilities meeting Medicare/CMS institutional coverage criteria. Specific facility and diagnosis requirements of Original Medicare apply (CMS-approved transplant centers as indicated).

See chunk 2 for full list

Enhanced bone marrow / stem cell transplant indications

Covered for Medicare Plus Blue Group PPO enhanced benefit when ALL listed condition-specific indications are met and the member is in an eligible Group PPO plan.

Allogeneic BMT/HCT indications: Allogeneic (donor) bone marrow or hematopoietic stem cell transplants are covered for osteopetrosis; renal cell cancer; and primary amyloidosis.

Chunk 4

Autologous BMT/HCT indications: Autologous (patient-derived) bone marrow or hematopoietic stem cell transplants are covered for renal cell cancer; germ cell tumors of ovary, testis, mediastinum, or retroperitoneum; neuroblastoma (stage III or IV); primitive neuroectodermal tumors; Ewing's sarcoma; medulloblastoma; Wilms' tumor; primary amyloidosis; and rhabdomyosarcoma.

Chunk 4

Second transplant: A second bone marrow transplant for multiple myeloma is covered after a failed first bone marrow transplant.

Chunk 4

Benefit period and drug coverage: All services except immunosuppressive and other transplant-related prescription drugs must be provided during the benefit period (begins five days before transplant and ends one year after transplant). When directly related to a covered transplant, Medicare Plus Blue Group PPO will pay for immunosuppressive drugs and other transplant-related prescription drugs during and after the benefit period.Benefit period = begins 5 days before transplant and ends 1 year after transplant

Chunks 4 and 5

This policy aligns coverage with Original Medicare National Coverage Determination 110.23. Original Medicare provides coverage for a defined list of organ and related procedures (for example: heart, heart-lung, lung, liver, lobar lung, bone marrow or stem cell, pancreas, kidney, corneal, simultaneous pancreas-kidney, intestinal, multi-visceral, stomach, duodenum, pancreas/liver/intestine/pancreatic tissue, and islet cell only in clinical trials). Coverage is contingent on services being performed in facilities that meet Medicare/CMS institutional and transplant center requirements where specified. The policy also reflects Medicare Plus Blue Group PPO enhanced benefits for certain bone marrow/stem cell indications when all condition-specific criteria are met and the member is in an eligible Group PPO plan.

Under NCD 110.23, certain stem cell transplants are explicitly excluded for specified conditions. Where Original Medicare limits coverage or requires performance in CMS-approved transplant centers, those scope and exclusion rules apply to Medicare Plus Blue Group PPO members. Refer to facility and candidate requirements for program certification expectations and to the benefit period rules for included pre- and post-transplant services.

Medicare distinguishes between autologous and allogeneic stem cell transplants and applies NCD 110.23 exclusions differently. Autologous stem cell transplants (AuSCT) are covered when consistent with Medicare policies and when performed in appropriate facilities, but AuSCT are not covered for several listed conditions under NCD 110.23, including acute leukemia not in remission, chronic granulocytic leukemia, most solid tumors other than neuroblastoma, tandem AuSCT for multiple myeloma, non-primary AL amyloidosis, and primary AL amyloidosis in beneficiaries age 65 and older.

Allogeneic stem cell transplants are similarly subject to NCD guidance; for example, allogeneic SCT is not covered for multiple myeloma under the NCD. Where the Group PPO provides enhanced bone marrow/stem cell benefits, coverage for specific autologous or allogeneic indications (for example: autologous coverage for certain solid tumors such as neuroblastoma and a set of hematologic malignancies; and allogeneic coverage for conditions such as osteopetrosis, renal cell cancer, primary amyloidosis) is only available when the listed condition-specific indications are met and the member is eligible under the enhanced benefit.

Coding and Benefit Period

Skin transplant CPT Codes (State Health Plan Medicare Advantage PPO only)CPTCovered

15271	Skin - CPT code listed for skin transplants
15272	Skin - CPT code listed for skin transplants
15273	Skin - CPT code listed for skin transplants
15274	Skin - CPT code listed for skin transplants
15275	Skin - CPT code listed for skin transplants
15276	Skin - CPT code listed for skin transplants
15277	Skin - CPT code listed for skin transplants
15278	Skin - CPT code listed for skin transplants

Benefit period

Benefit period startBegins 5 days before the transplant

Benefit period endEnds 1 year after the transplant

Applies toAll transplant-related services except immunosuppressive prescription drugs must be provided during this period

Provider Actions and Billing

Prior Authorization

Prior Authorization Not Required for Covered Transplants

Prior authorization is not required for covered human organ transplants when performed at Medicare-certified facilities. Providers may perform covered transplants at facilities outside the Blue Cross network provided the facility has a Medicare provider agreement and is CMS-certified for the relevant procedure.

Medicare-certified/CMS-approved transplant facilities — no prior authorization for covered transplants
Members may receive care at non-Blue Cross facilities if CMS-certified

Note

Provider Note

For provider reference: confirm facility CMS certification and Medicare provider agreement before scheduling transplant services to ensure coverage consistency with Original Medicare requirements.

Background

Human organ transplant replaces a damaged or failing organ with a working organ from a living or deceased donor, or with tissue from a donor site on the patient. Transplants can be lifesaving procedures (whole organs) or life-enhancing (tissue), and typically require multidisciplinary evaluation, specialized surgical care, and ongoing follow-up including immunosuppression when applicable.

Original Medicare transplant coverage typically includes necessary preoperative tests, labs and exams, the transplant procedure itself (when performed in CMS-approved centers as required), procurement of organs, follow-up care, and—in certain circumstances—immunosuppressive drugs. Islet cell transplants are covered only in the context of approved clinical trials under Original Medicare.

Definitions

Human organ transplant — definition

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 typesOrgan donors may be living or deceased

PurposeReplaces a recipient's damaged or failing organ with a working organ

Candidate and Facility Criteria

Candidate and facility criteria

Eligibility follows Original Medicare coverage and the Group PPO enhanced-list where applicable.

Facility and program requirements: Transplants must be performed in CMS-approved transplant centers; Original Medicare institutional coverage criteria apply. Facility must meet Medicare/CMS transplant center requirements to ensure payment eligibility.

Chunks 2,4,6

Contraindications

Documented contraindications in Medicare NCD 110.23 render specific stem cell transplant indications noncovered. Notable Medicare exclusions include autologous stem cell transplants for: acute leukemia not in remission, chronic granulocytic leukemia, solid tumors other than neuroblastoma, tandem AuSCT for multiple myeloma, non-primary AL amyloidosis, and primary AL amyloidosis for beneficiaries age 65 and older. Additionally, allogeneic stem cell transplants are not covered for multiple myeloma under the NCD.

Evaluation Requirements

Documentation Required

Complete required preoperative evaluations and refer to transplant center

Ensure necessary preoperative tests, labs and exams are completed as covered under Original Medicare and consider referral to the transplant center or Blue Cross Case Management for supportive services prior to transplant.

Complete all preoperative evaluations required by the transplant center and Original Medicare guidance
Refer members to transplant centers and to Blue Cross Case Management when appropriate

Center Requirements

Step Therapy

Use CMS‑certified transplant centers meeting Medicare institutional criteria

Provide transplant services only at transplant centers certified by CMS and meeting Original Medicare institutional coverage criteria; CMS-approved center certification is required for covered organ transplants.

Post-Transplant Coverage

Transplant-related services and immunosuppressive drugs

Service timing requirementAll transplant-related services except immunosuppressive prescription drugs must be provided during the benefit period (begins 5 days before transplant and ends 1 year after transplant)

Immunosuppressive drug coverage (covered transplants)When directly related to a covered transplant, immunosuppressive and other transplant-related prescription drugs are paid during and after the benefit period by Medicare Plus Blue Group PPO

Immunosuppressive drug responsibility (noncovered transplants)For noncovered transplants, the member's prescription drug plan is responsible for immunosuppressive and other transplant-related prescription drugs