Organ and tissue transplantation services
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Defines UnitedHealthcare coverage, prior authorization, designated facility requirements, and covered vs. not-covered transplant services for members; applies to UnitedHealthcare benefit plans subject to federal/state mandated regulations.
Clarified that bone marrow and peripheral stem cell transplants, including CAR-T cell therapy, are covered whether autologous or allogeneic and with or without high dose chemotherapy.
Replaced wording about inpatient oral/dental examination being part of a comprehensive work up with language stating it is covered as part of a pretransplant evaluation.
Reworded storage-costs coverage sentence to state storage costs for organ or bone marrow are covered when part of an authorized treatment protocol.
Coverage Criteria for Transplant Services
General transplant coverage criteria
Covered when ALL of the following are met
Refer to the Medical Necessity policy and the member's EOC/SOB for plan-specific provisions
Covered transplant procedures
Specific covered transplant procedures
If OptumHealth Transplant Solutions determines an unlisted transplant is proven, it may be covered
Covered transplant-related services
Covered transplant-related services when criteria met
Refer to the member's EOC/SOB for specific requirements, limitations, and financial responsibilities
The policy excludes several specific items from coverage. Not covered are artificial heart implantation, duplicated diagnostic costs for a transplant review at a second regional organ procurement facility, and non-human organ transplantation. The policy also excludes equipment and medications that are experimental, investigational, or not medically necessary (see the Medical Necessity policy for determination). Additionally, storage costs for any organ or bone marrow are not covered unless the conditions described in the Covered Benefits section are met, and transplant services performed when the recipient is not a UnitedHealthcare member are excluded.
Procedures, equipment, or medications determined to be experimental, investigational, or not medically necessary are excluded from coverage under this policy. The Medical Necessity (Benefit Interpretation) policy is the governing reference for those determinations. Transplants must be non-experimental and medically necessary and performed at a UnitedHealthcare designated facility to be eligible for coverage.
Coding and Listing Rules
| No codes listed |
Provider Actions, Authorization and Documentation
Prior authorization required for all transplants
All transplant procedures must be prior authorized by UnitedHealthcare and must be performed at a UnitedHealthcare designated facility.
- Prior authorization is required for pre- and post-operative medical, surgical, and hospital services related to transplant.
- Designated-facility requirement derives from regulations requiring care at centers designated by the plan.
Utilization management and cost-control tools may be used
UnitedHealthcare may apply utilization review, case management, prior authorization, network requirements, and other cost-control mechanisms consistent with clinical guidelines and the member's plan contract.
- Use of case management, utilization review techniques, prior authorization and network provider requirements is permitted under applicable law and plan contract.
- These processes must be consistent with sound clinical processes and guidelines and with the member's Evidence of Coverage/Schedule of Benefits (EOC/SOB).
Document pre-transplant testing and facility designation
Pre-transplant evaluation must include appropriate testing such as histocompatibility (typing) for the recipient and donor; documentation that the facility is UnitedHealthcare-designated and that prior authorization was obtained should be included in the record.
- Histocompatibility testing required for recipient and donor when the intended recipient is a UnitedHealthcare member; testing of immediate blood relatives limited to siblings, parents, and natural children.
- Providers should document facility designation by UnitedHealthcare and evidence of prior authorization in the member record and refer to the member's EOC/SOB for plan-specific provisions.
Denial risk: non-designated, unauthorized, or ineligible recipient
Services will be denied if the transplant or related services are performed in a non-UnitedHealthcare designated facility, if services are unauthorized or not prior authorized, or if the transplant recipient is not a UnitedHealthcare member.
- Transplantation performed in a non-UnitedHealthcare designated facility is not covered and may be denied.
- Unauthorized or not prior authorized organ procurement and transplant-related services are not covered.
- Services for recipients who are not UnitedHealthcare members are excluded from coverage.
Candidate Selection and Eligibility
Candidate selection
Selection and eligibility criteria
Refer to center selection processes and UnitedHealthcare prior authorization requirements
Pre-Transplant Evaluation Requirements
Pre-transplant evaluation must include histocompatibility testing
Pre-transplant testing and evaluation must include histocompatibility testing for both recipient and donor, and testing of immediate blood relatives is limited to sisters, brothers, parents, and natural children when the recipient is a UnitedHealthcare member.
- Include donor search and testing and donor-related testing per EOC/SOB limits.
- Ensure immediate relative testing is limited to siblings, parents, and natural children as specified.
Designated Facility / Center Requirements
Use UnitedHealthcare-designated transplant centers only
Transplant centers must be designated by UnitedHealthcare as having documented skills, resources, commitment, and a record of favorable outcomes; transplants must be performed at these designated centers.
- Designation requirement is per California regulation: care provided at centers designated by the participating health plan.
- UnitedHealthcare will pay for transplant surgery and related inpatient services at the facility that performs the transplant, which must be a designated center.
Post-Transplant Coverage and Immunosuppression
Contraindications
Contraindications are addressed through application of medical necessity determinations and relevant clinical guidelines rather than by listing explicit absolute contraindications in this document. Providers should follow established clinical guidance and the Medical Necessity policy when evaluating potential contraindications for transplantation; review and prior authorization decisions will reflect those standards.
Background and Scope
This policy restates applicable federal and state-mandated transplant benefit requirements and UnitedHealthcare’s coverage approach. It specifies that human organ and tissue transplants are limited to non-experimental and non-investigational procedures determined to be medically necessary and that all transplant procedures must be prior authorized by UnitedHealthcare and performed in a UnitedHealthcare designated facility. The policy also notes that providers and members should consult the member’s Evidence of Coverage/Schedule of Benefits for plan-specific provisions and that UnitedHealthcare will periodically review new clinical evidence to update covered transplant procedures.
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