Transplant Program coverage for organ, cornea, and stem cell transplants
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Defines MemorialCare Select Health Plan coverage, prior authorization, case coordination, and covered services for solid organ, cornea, and bone marrow/stem cell transplants for plan members; applies to MemorialCare Select Health Plan members and participating providers and transplant centers.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Covered Services
Covered when services are medically necessary and not considered experimental or investigative and when prior authorization and network requirements are met.
Supported by policy statement about coverage and network selection.
inv-02: Transplant Types Requiring Authorization
The following transplants are covered when prior authorization is obtained and when medically necessary:
Each listed transplant requires prior authorization and medical necessity.
inv-03: Case Rate Components
Covered services during the case rate period include:
Lists professional components included in case rate.
Institutional components included in case rate.
Outpatient pharmacy-covered meds are excluded from case rate.
inv-04: Bone Marrow / Peripheral Stem Cell Transplant Coverage
Bone marrow transplant donor testing and procedures covered when transplant is authorized:
Coverage tied to authorization for allogeneic transplant.
Non-transplant services and certain pre-transplant cancer therapies are excluded from the transplant case rate and are not covered as part of transplant benefits. Specifically, non-transplant related services are excluded, and any chemotherapy or radiation therapy (for example, induction, consolidation, or adjuvant) performed prior to high-dose chemotherapy is excluded from the case rate and must be processed according to the provider's current Participation Agreement (PPA).
Any transplant that is considered experimental or investigative is not covered under this policy, except when coverage is granted through approval by an independent review organization or third-party reviewer. Requests for coverage of such transplants must follow the independent review process to be considered for payment.
Provider Actions and Requirements
Prior authorization required
Prior authorization is required for the listed transplants and unrelated donor searches must receive prior authorization from MemorialCare Select Health Plan's transplant care managers before beginning the search.
Step therapy not specified
The policy does not specify any step therapy requirements for transplant services.
Submit clinical documentation for medical necessity review
Upon receipt of a transplant request, MemorialCare Select Health Plan's transplant case manager will request clinical documentation and review it with the Chief Medical Officer or designee to determine medical necessity and benefit coverage.
Unauthorized transplants are not covered
Transplant coverage will not be extended if the transplant was not authorized by MemorialCare Select Health Plan.
Post-transplant care denied for out-of-network procedures
Post-transplant care for current members is not covered if the transplant procedure was not approved by MemorialCare Select Health Plan and was performed at a facility that is not a MemorialCare Select Health Plan Transplant Center.
Candidate Referral and Evaluation
inv-14: Candidate Referral and Evaluation
Referral and evaluation workflow for potential transplant candidates:
Includes timelines, documentation review, and coordination steps.
Evaluation Requirements
Evaluation documentation required for medical necessity determination
Clinical documentation must be submitted to the transplant case manager for review with the Chief Medical Officer or designee to determine medical necessity and benefit coverage before authorization is issued.
- Case manager will request documentation upon receipt of a transplant request.
- Documentation is reviewed with the Chief Medical Officer or designee to determine medical necessity and benefit coverage.
Post-Transplant Coverage and Case Management
Transplant Center Requirements
Use Optum Centers of Excellence and meet facility/program standards
MemorialCare Select Health Plan uses the Optum Adult and Pediatric Transplant Centers of Excellence network; the network and facility/program standards are evaluated annually and facility selection and payment methodology are determined by contract.
- Providers must coordinate and obtain authorizations for transplant-related care and use plan-preferred or Optum-designated Centers of Excellence per contract.
- Optum's pediatric program selection reflects volume and complexity and the network is evaluated annually to ensure standards of care.
Definitions
Background
Transplantation coverage encompasses the full episode of care surrounding an organ or tissue transplant. This includes pre-transplant evaluation, the process of organ acquisition, the operative procedure itself, and post-operative care. Many of these services are paid as a bundled case rate, with exclusions noted elsewhere in the policy (see exclusions for non-transplant services and pre–high-dose chemotherapy therapies).
Contraindications
Contraindications for transplantation are not explicitly listed in this policy document.
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