CurrentBlue Cross Complete of MichiganPolicy N/A

Human Organ Transplant

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Medicare Advantage coverage, enhanced benefit coverage, payment conditions, facility requirements, and billing for human organ, tissue, bone marrow, and hematopoietic stem cell transplants, primarily for BCN Advantage Group HMO members and providers in Michigan.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyHuman Organ Transplant

Policy CodePolicy N/A

Change TypeTemplate transitionno material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify benefits and member cost sharing through the provider portal or by calling BCN Advantage before furnishing services when coverage or cost sharing is uncertain.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15+Covered transplant types

CMS-approvedFacility requirement

Not requiredPrior authorization

Group HMO onlyEnhanced benefit eligibility

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CurrentBlue Cross Complete of MichiganPolicy N/A

Human Organ Transplant

Customize your policy alerts

Sign up for all blue_cross_complete_of_michigan policy alerts

Know when blue_cross_complete_of_michigan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyHuman Organ Transplant

Policy CodePolicy N/A

Change TypeTemplate transitionno material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify benefits and member cost sharing through the provider portal or by calling BCN Advantage before furnishing services when coverage or cost sharing is uncertain.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15+Covered transplant types

CMS-approvedFacility requirement

Not requiredPrior authorization

Group HMO onlyEnhanced benefit eligibility

Benefit and payment changes

RequiredReimbursement policy review

Transplant Coverage Criteria

Original Medicare transplant coverage

Covered when the transplant is covered by Original Medicare and applicable facility requirements are met.

Original Medicare-covered transplant: The transplant procedure is one of the procedures covered by Original Medicare, and the applicable Medicare facility requirements are satisfied.CMS-approved transplant facility when required

Covered procedures include heart, heart-lung, lung, lobar lung, liver, bone marrow or stem cell, pancreas, kidney, corneal, simultaneous pancreas-kidney, intestinal, multi-visceral, stomach, duodenum, combined pancreas/liver/intestine/pancreatic tissue, and islet cell transplantation only in a clinical trial.

Enhanced Group HMO transplant benefit

Enhanced benefit coverage is available only to members under select BCN Advantage Group HMO plans when the applicable condition and transplant type are met.

Covered enhanced-benefit transplant indication: The member requires an eligible bone marrow or hematopoietic stem cell transplant for one of the listed conditions.Listed diagnosis and transplant type

Eligible categories are allogeneic transplantation for osteopetrosis, renal cell cancer, or primary amyloidosis; autologous transplantation for renal cell cancer, specified germ cell tumors, stage III or IV neuroblastoma, primitive neuroectodermal tumors, Ewing's sarcoma, medulloblastoma, Wilms' tumor, primary amyloidosis, or rhabdomyosarcoma; or a second bone marrow transplant for multiple myeloma after failure of the first transplant.

Stem cell transplant treatment phases

When covered, stem cell transplant coverage includes all phases of treatment.

Covered stem cell transplant phases: The covered treatment includes mobilization, harvesting, high-dose radiotherapy or chemotherapy before transplantation, and infusion of stem cells.All treatment phases

Coverage remains subject to applicable Medicare conditions and exclusions.

Stem cell transplant exclusions

Not covered under the cited Medicare stem cell transplant coverage rules when any of the following exclusions applies.

Excluded stem cell indication

Excluded autologous indication: The autologous stem cell transplant is for acute leukemia not in remission, chronic granulocytic leukemia, a solid tumor other than neuroblastoma, tandem transplantation for multiple myeloma, or non-primary AL amyloidosis.
Age-specific autologous exclusion: The autologous stem cell transplant is for primary AL amyloidosis in a Medicare beneficiary age 65 or older.Age 65 or older
Excluded allogeneic indication: The allogeneic stem cell transplant is for multiple myeloma.

Under NCD 110.23, the following stem cell transplant indications are not covered: autologous transplantation for acute leukemia not in remission, chronic granulocytic leukemia, solid tumors other than neuroblastoma, tandem transplantation for multiple myeloma, non-primary AL amyloidosis, or primary AL amyloidosis in Medicare beneficiaries age 65 and older; and allogeneic transplantation for multiple myeloma.

Islet cell transplantation is covered only when performed in the context of a clinical trial. Islet cell transplantation outside a qualifying clinical trial is not covered.

The enhanced transplant benefit is available only to members enrolled in select BCN Advantage Group HMO plans. Member reimbursement and cost sharing are determined by the member's group benefit. The policy does not state that this enhanced benefit is available to Individual plans.

Transplant Candidate Eligibility

Transplant candidate coverage

A member is a candidate for coverage when the transplant qualifies through either the Original Medicare pathway or an enhanced Group HMO pathway, and applicable facility and transplant requirements are met.

Coverage pathway
- Original Medicare pathway: The transplant procedure is covered by Original Medicare and meets applicable Original Medicare conditions.
- Enhanced Group HMO pathway: The member is enrolled in a select BCN Advantage Group HMO plan and the transplant qualifies under the enhanced transplant benefit.
Facility and procedure requirements: The transplant is performed at a facility meeting applicable Medicare, CMS, or plan requirements.

Transplant Contraindications

Contraindicated or excluded autologous stem cell transplant indications under NCD 110.23 include 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 in Medicare beneficiaries age 65 and older.

Allogeneic stem cell transplantation for multiple myeloma is excluded under NCD 110.23. Islet cell transplantation is also excluded when it is not performed in the context of a clinical trial.

Pre-Transplant Evaluation

Documentation Required

Complete the required transplant evaluation

When the transplant is covered, include the necessary tests, laboratory services, and examinations performed before surgery. For covered stem cell transplants, coverage includes mobilization, harvesting, high-dose radiotherapy or chemotherapy before transplantation, and infusion of stem cells.

Preoperative tests, laboratory services, and examinations
Stem cell transplant treatment phases: mobilization, harvesting, high-dose radiotherapy or chemotherapy before transplantation, and stem cell infusion

Facility and Transplant Center Requirements

Documentation Required

Confirm the facility meets transplant requirements

Verify that the transplant facility has a Medicare provider agreement and is certified by CMS for the relevant covered procedure. Specified solid organ transplants must be performed in CMS-approved transplant centers, and Original Medicare facility requirements apply to all organ transplant procedures.

Medicare provider agreement
CMS certification for the relevant covered procedure
CMS-approved transplant center for specified solid organ transplants
Original Medicare facility requirements

Applicable Coverage References

Applicable CMS coverage referencesmixed

NCD 110.23	Stem Cell Transplantation (Formerly 110.8.1)
NCD 260.1	Adult Liver Transplantation
NCD 260.2	Pediatric Liver Transplantation
NCD 260.3	Pancreas Transplants
NCD 260.3.1	Islet Cell Transplantation in the Context of a Clinical Trial
NCD 260.5	Intestinal and Multi-Visceral Transplantation
NCD 260.9	Heart Transplants
LCD L39477	Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

Billing, Documentation, and Coverage Alerts

Billing Rule

Submit complete claims

Submit claims on the CMS-1500 (02/12), UB-04, or equivalent 837 claim form using BCN Advantage billing requirements. Report CPT/HCPCS and diagnosis codes to the highest level of specificity and include the provider’s National Provider Identifier on all claims.

Send electronic and paper claims to BCN Advantage
Report CPT/HCPCS and diagnosis codes to the highest level of specificity
Report the provider’s National Provider Identifier on all claims

Billing Rule

Follow out-of-area Blue plan billing instructions

Providers outside Michigan should follow applicable electronic or paper billing instructions through their local Blue plan. Providers participating with Blue plans may provide preauthorized routine and follow-up care as necessary for BCN Advantage HMO-POS members.

Transplantation Overview

Human organ transplantation is a surgical procedure that replaces a damaged or failing whole or partial organ with a functioning organ or tissue. The transplant may use an organ from a living or deceased donor or tissue obtained from the patient's own body. An allogeneic transplant uses cells, tissue, or an organ from another person, while an autologous transplant uses cells or tissue from the patient.

Transplant Terminology

Human organ transplant

DefinitionThe surgical 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 the recipient’s damaged or failing organ with a working one.

Donor sourceThe organ may come from a living or deceased donor, or from the patient’s own body.

PurposeThe transplant replaces a damaged or failing organ with a working organ.

Allogeneic transplant

DefinitionA transplant from a donor.

Donor sourceThe transplanted cells, tissue, or organ come from another person rather than the patient.

Follow-Up Care and Immunosuppressive Drugs

Post-transplant follow-up care

ServicePost-transplant follow-up care.

Coverage basisFollow-up care is included in Original Medicare transplant coverage.

Coverage conditionFollow-up care is included when the transplant is covered.

Immunosuppressive drugs

MedicationImmunosuppressive drugs.

Coverage basisImmunosuppressive drugs are included in Original Medicare transplant coverage.

Coverage condition

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyHuman Organ Transplant

Policy CodePolicy N/A

Change TypeTemplate transitionno material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify benefits and member cost sharing through the provider portal or by calling BCN Advantage before furnishing services when coverage or cost sharing is uncertain.

SourceLink

On This Page

CMS-approved facility when required

Original Medicare facility requirements apply to all organ transplant procedures; applicable facilities must have a Medicare provider agreement and CMS certification for the relevant covered procedure.

Contact the local Blue plan for billing instructions
Confirm Blue plan participation for applicable out-of-area care
Provide preauthorized routine and follow-up care as necessary for BCN Advantage HMO-POS members

Documentation Required

Submit medical records when required

Providers not contracted with BCBSM or BCN’s Medicare Advantage network may be required to submit documentation supporting billed claims, including applicable medical records.

Supporting documentation for billed claims
Applicable medical records, when required

Note

Verify benefits before providing services

Verify benefits and member cost sharing through the provider portal or by calling BCN Advantage before furnishing services when coverage or cost sharing is uncertain.

Use the provider portal or call 1-800-344-8525
Verify coverage before providing an item or service when coverage is uncertain
Verify the member’s applicable cost sharing

Billing Rule

Follow reimbursement and claim policies

Review applicable BCBSM reimbursement policies before submitting a claim and bill covered services in accordance with those policies. Contracted providers should also review the provider manual for additional claim submission requirements.

Review applicable BCBSM reimbursement policies
Bill covered services in accordance with those policies
Review the provider manual if contracted with BCBSM or BCN’s Medicare Advantage network

Denial Risk

Avoid nonapproved transplant facilities

Coverage may be denied when a covered organ transplant is performed at a facility that does not have a Medicare provider agreement or CMS certification for the relevant procedure, or when Original Medicare facility requirements are not met.

Confirm the facility has a Medicare provider agreement
Confirm CMS certification for the relevant procedure
Use a CMS-approved transplant facility when required

Denial Risk

Screen for excluded stem cell indications

Under NCD 110.23, autologous stem cell transplants are not covered for acute leukemia not in remission, chronic granulocytic leukemia, solid tumors other than neuroblastoma, tandem transplantation for multiple myeloma, non-primary AL amyloidosis, or primary AL amyloidosis in Medicare beneficiaries age 65 and older. Allogeneic stem cell transplantation for multiple myeloma is also not covered.

Autologous: acute leukemia not in remission
Autologous: chronic granulocytic leukemia
Autologous: solid tumors other than neuroblastoma
Autologous: tandem transplantation for multiple myeloma
Autologous: non-primary AL amyloidosis
Autologous: primary AL amyloidosis for Medicare beneficiaries age 65 and older
Allogeneic: multiple myeloma

Denial Risk

Confirm the islet cell clinical trial requirement

Islet cell transplantation is covered only when performed in the context of a clinical trial. Confirm that the transplant meets this restriction before furnishing the service.

Coverage is limited to islet cell transplantation performed in a clinical trial

Denial Risk

Verify eligibility for the enhanced benefit

The enhanced transplant benefit is limited to members under select BCN Advantage Group HMO plans. Member reimbursement and cost sharing are determined by the member’s group benefit, so verify the member’s plan-specific coverage before providing the service.

Confirm enrollment in a select BCN Advantage Group HMO plan
Verify the applicable group benefit
Confirm member reimbursement and cost-sharing conditions

Denial Risk

Follow the rules for noncovered services

If a member elects to receive a noncovered service, the member is responsible for the entire charge. Do not use an Advance Beneficiary Notice of Noncoverage to obtain responsibility for a noncovered item; if coverage is uncertain, obtain a coverage determination from BCN Advantage first.

Collect only the appropriate BCN Advantage cost-sharing amount for covered services
Seek a coverage determination before providing an item when coverage is uncertain
If a noncovered item is provided without first obtaining a coverage determination, hold the member harmless for all charges except applicable cost sharing

The enhanced benefit lists allogeneic transplants for osteopetrosis, renal cell cancer, and primary amyloidosis.

Autologous transplant

DefinitionA transplant using cells or tissue from the patient.

Patient sourceThe cells or tissue used for the transplant come from the same patient who receives the transplant.

Policy examplesThe enhanced benefit lists autologous transplants for conditions including renal cell cancer, specified germ cell tumors, neuroblastoma, primary amyloidosis, and rhabdomyosarcoma.

Coverage applies under certain conditions after a covered transplant.