CurrentUnitedHealthcarePolicy BIP015.O

Blood and Blood Products: CA – UnitedHealthcare West Benefit Interpretation Policy

Defines UnitedHealthcare West coverage and exclusions for use and administration of blood and blood components (e.g., cryoprecipitate, platelets, plasma, albumin, gamma globulin, fibrinogen, clotting factors) in inpatient and outpatient settings, including autologous/donor-directed processing costs and bloodless surgery with prior authorization. References member Evidence of Coverage for plan-specific provisions.

Policy Summary

PayerUnitedHealthcare

PolicyBlood and Blood Products: CA – UnitedHealthcare West Benefit Interpretation Policy

Policy CodePolicy BIP015.O

Change TypeRoutine reviewno change

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization for bloodless surgery for coverage to apply.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

7Examples of covered blood products listed

Coverage Summary

This policy defines UnitedHealthcare West coverage and exclusions for the use and administration of blood and blood components (including but not limited to cryoprecipitate, platelets, fibrinogen, plasma, gamma globulin, albumin, and clotting factors) in both inpatient and outpatient settings. It also addresses autologous (self-donated) and donor-directed processing costs, coverage for blood collected but not used when authorized by a physician, and bloodless surgery (procedures without transfusions or blood products, including Rho(D) immune globulin) which requires medical necessity and prior authorization. Refer to the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB) for plan-specific limitations and provisions. State and federal mandated regulations and state market plan enhancements: None.

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Medical-Necessity Criteria

Covered Benefits

Covered when ALL of the following apply:

Use and administration of blood and blood components (including but not limited to cryoprecipitate, platelets, fibrinogen, plasma, gamma globulin, albumin) are covered when medically necessary.

Refer to member EOC/SOB for plan-specific provisions.

Blood provided through a blood bank is covered on either an inpatient or outpatient basis.

Blood clotting factors for hemophilia patients are covered when coverage criteria are met.

Autologous (self-donated) and donor-directed (donor-designated) blood processing costs are covered only for a scheduled procedure, including storage fees charged as a result of physician and/or provider cancellations that are beyond the member's control.

Limit applies to scheduled procedures only.

Cost of blood collected but not used is covered if the physician authorized the need.

Bloodless surgery (procedures performed without blood transfusions or blood products, including Rho(D) immune globulin) is covered when medically necessary and prior authorization is obtained.

Prior authorization required.

Not Covered

The following are not covered:

Blood charges associated with non-authorized or non-covered procedures.

Claims for such charges are subject to denial.

Required Provider Actions

Prior Authorization

Prior authorization for bloodless surgery

Obtain prior authorization for bloodless surgery (procedures performed without transfusions or blood products, including Rho(D) immune globulin) for coverage to apply.

Documentation Required

Medical necessity documentation

Document medical necessity for the use and administration of blood and blood components and for coverage of blood clotting factors in hemophilia patients per the coverage criteria and the member's Evidence of Coverage/Schedule of Benefits.

Billing Rule

Autologous/donor-directed processing billing constraint

Autologous (self-donated) and donor-directed (donor-designated) blood processing costs are covered only for scheduled procedures; storage fees charged due to physician/provider cancellations beyond the member's control are included.

Denial Risk

Non-authorized procedure charges

Claims for blood charges tied to procedures that are not authorized or not covered are subject to denial.

Background, Evidence & Definitions

Covered benefits include the use and administration of blood and blood components (examples listed: cryoprecipitate, platelets, fibrinogen, plasma, gamma globulin, albumin), blood provided through a blood bank on either an inpatient or outpatient basis, and blood clotting factors for hemophilia patients when coverage criteria are met. Autologous and donor-directed blood processing costs are covered only for a scheduled procedure (including storage fees charged for provider/physician cancellations beyond the member's control). The cost of blood collected but not used is covered if the physician authorized the need. Bloodless surgery without transfusions or blood products (including Rho(D) immune globulin) is covered when medically necessary and prior authorization is obtained.

Refer to the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB) for plan-level limitations and specific provisions. State and federal mandated regulations and state market plan enhancements: None.

American Red Cross, Blood Components. Accessed February 2026.

Term	Definition
Bloodless Surgery	Surgical procedures performed without blood transfusions or blood products; coverage requires medical necessity and prior authorization.

OpenPayer

Blood and Blood Products: CA – UnitedHealthcare West Benefit Interpretation Policy

Coverage Summary

Medical-Necessity Criteria

Required Provider Actions

Coding

Background, Evidence & Definitions

Revision History