UnitedHealthcare Transplant Coverage Prior Auth Update

Coverage Criteria

Covered transplant services

Covered when ALL of the following are met:

General covered conditions: (1) The transplant procedure is non-experimental and medically necessary per the Medical Necessity policy; (2) The procedure is prior authorized by UnitedHealthcare; (3) The transplant is performed at a UnitedHealthcare designated facility; (4) Donor and recipient testing and pre-transplant evaluation are completed as required, including histocompatibility testing for recipient and donor when the recipient is a UnitedHealthcare member; (5) Coverage limits and plan-specific provisions in the member's Evidence of Coverage/Schedule of Benefits are satisfied.

Includes pre- and post-operative medical/surgical/hospital services and medically necessary ambulance transportation to the designated facility; storage costs only as part of an authorized treatment protocol; outpatient post-transplant immunosuppressive drug therapy covered only if member has supplemental pharmacy benefit or pharmacy is part of the basic plan.

The following services and items are not covered under this transplant policy: artificial heart implantation; non-human organ transplantation; equipment or medication that is experimental, investigational, or not medically necessary (see the Medical Necessity policy). Storage costs for any organ or bone marrow are excluded unless the conditions specified in the Covered Benefits section are met. Coverage is also excluded for transplant services when the recipient is not a UnitedHealthcare member, for transplantation performed in a non-UnitedHealthcare designated facility, for transportation of potential donors for typing/matching, and for unauthorized or not prior authorized organ procurement and transplant-related services.

Any transplant procedure, related service, equipment, or medication that is determined to be experimental or investigational, or that does not meet the plan’s definition of medical necessity per the Benefit Interpretation Policy titled Medical Necessity, is not covered. Providers should ensure that requests meet medical necessity criteria and obtain prior authorization, as services that are investigational or not medically necessary will be denied.

Coding and Related Definitions

Covered transplant types (listed)mixedCovered

Bone marrow transplants	Bone marrow transplants (either from the member or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy, including chimeric antigen receptor (CAR)-T cell therapy.
Heart	Heart
Heart/lung	Heart/lung
Lung	Lung
Kidney	Kidney
Kidney/pancreas	Kidney/pancreas
Liver	Liver
Liver/small bowel	Liver/small bowel
Pancreas	Pancreas
Small bowel	Small bowel

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Not covered procedures (listed)mixedNot Covered

Artificial heart implantation	Artificial heart implantation
Non-human organ transplantation	Non-human organ transplantation
Experimental/investigational equipment or medication	Equipment and medication that is experimental/investigational and/or not medically necessary
Storage costs (unless criteria met)	Storage costs of any organ or bone marrow unless criteria in the Covered Benefits section are met
Transplant services for non-members	Transplant services when the transplant recipient is not a UnitedHealthcare member
Transplantation in non-designated facility	Transplantation performed in a non-UnitedHealthcare designated facility
Transportation of potential donor for typing/matching	Transportation of any potential donor for typing and matching
Unauthorized or not prior authorized services	Unauthorized or not prior authorized organ procurement and transplant related services
Member transportation/food/housing (not eligible)	Transportation, food, and housing expenses of the member when the member is not receiving medically necessary transplant services or above and beyond the allowed benefit
Living donor non-clinical expenses	Transportation and other non-clinical expenses of a living donor

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Immediate blood relatives tested for marrow/stem cell compatibility — limited to sisters, brothers, parents, and natural children

Scope of testingTesting of immediate blood relatives to determine compatibility for bone marrow and stem cell transplants is limited to sisters, brothers, parents, and natural children.

Applies to recipients who are UnitedHealthcare membersHistocompatibility testing for the transplant recipient and donor is covered when the intended recipient is a UnitedHealthcare member.

Relation restriction detailOnly immediate blood relatives (sisters, brothers, parents, natural children) are eligible for compatibility testing; other relatives or unrelated donors are not included in this specific testing allowance.

Provider Actions and Administrative Requirements

Prior Authorization

Prior Authorization Required

All transplant procedures must be prior authorized by UnitedHealthcare and performed at a UnitedHealthcare designated facility. Contact OptumHealth Transplant Solutions for prior authorization, facility designation, and transplant coordination. Providers should use the UnitedHealthcare Provider Portal (chat 24/7) or Member Services for referrals, eligibility verification, and operational navigation; additional contact details are available at UHCprovider.com > Contact Us.

Prior authorization required for all transplant procedures
Transplants must be performed at a UnitedHealthcare designated facility
OptumHealth Transplant Solutions handles determination of additional covered transplants and coordination

Note

Utilization Controls and Plan Processes

UnitedHealthcare may use utilization management techniques consistent with applicable law and the plan contract, including utilization review, prior authorization, case management, and use of network providers. Providers must follow any plan-specific utilization controls and the member's Evidence of Coverage/Schedule of Benefits for details on cost-sharing and benefit limits.

Candidate Selection and Eligibility

Candidate selection

Regulatory and plan-level candidate selection requirements:

Candidate selection and testing: Patients shall be selected by the patient-selection committee of designated centers and are subject to prior authorization; designated centers must meet plan requirements for skills, resources, commitment and record of favorable outcomes; histocompatibility testing for the transplant recipient and donor when the intended recipient is a UnitedHealthcare member is covered; testing of immediate blood relatives to determine marrow/stem cell compatibility is limited to sisters, brothers, parents, and natural children.

References California regulation for center designation and patient-selection committee; testing limits per UnitedHealthcare coverage language.

Pre-Transplant Evaluation Requirements

Note

Pre-transplant evaluation, testing, and organ acquisition requirements

Complete pre-transplant evaluation and testing as required, including histocompatibility testing for recipient and donor, organ acquisition processes, and any inpatient pre-operative oral/dental exam when part of the workup; note limits on testing of immediate blood relatives and pharmacy coverage for post-transplant immunosuppression.

Pre-transplant testing and evaluation, including histocompatibility testing for recipient and donor, is covered when the recipient is a UnitedHealthcare member.
Testing of immediate blood relatives for marrow/stem cell compatibility is limited to sisters, brothers, parents, and natural children.
Organ acquisition from cadaver or living donor is covered as specified.
An oral or dental examination performed inpatient as part of the comprehensive pre-transplant workup is covered.
Outpatient post-transplant immunosuppressive drug therapy is covered only if the member has a supplemental pharmacy benefit or pharmacy is part of the basic plan.

Contraindications

Member HIV infection status shall not be used as a basis to deny coverage for solid organ or other tissue transplantation services. HIV infection alone is not a contraindication to coverage and plans must not deny transplant benefits solely on the basis of a member’s HIV status.

Definitions

Designated facility definition — Facility designated by the participating health plan with documented skills, resources, commitment and record of favorable outcomes

DefinitionFacility designated by the participating health plan as having documented skills, resources, commitment and record of favorable outcomes to qualify to provide transplant care.

Designated-center requirementPre-operative evaluation, surgery and follow-up care shall be provided at centers designated by the participating health plan.

Operational noteUnitedHealthcare requires transplants to be performed at a UnitedHealthcare designated facility for coverage; consult UHC resources for designated center listings.

HIV infection non-exclusion — Member HIV infection status shall not be a basis to deny coverage for transplants

Non-exclusion statementA health care service plan shall not deny coverage for solid organ or other tissue transplantation services based upon the enrollee or subscriber being infected with human immunodeficiency virus (HIV).

Post-Transplant Coverage and Support

Surgical and post-transplant services, donor inpatient services, storage costs (conditional) — facility-based coverage for surgery and donor services

Facility-based surgical coverageUnitedHealthcare will pay for transplant surgery and posttransplant services at the facility that performs the transplant.

Donor inpatient servicesUnitedHealthcare covers living donor inpatient services and surgery; covered services for living donors are limited to medically necessary clinical services once a donor is identified.

Storage costs (conditional)Storage costs of any organ or bone marrow are covered only as part of an authorized treatment protocol as determined by the UnitedHealthcare designated facility medical director or designee.

Transportation, food, and housing (conditional) — coverage subject to specific requirements and limits in the member documents

Member and one escortTransportation, food, and housing expenses for the member and one escort to the UnitedHealthcare designated facility are covered subject to specific requirements and limits in the member's Evidence of Coverage/Schedule of Benefits.

Background

This policy governs coverage for solid organ and tissue transplantation and related pre‑ and post‑operative services when medically necessary and non‑investigational. Covered transplant types include, but are not limited to, heart, lung, liver, kidney, bone marrow/hematopoietic stem cell transplantation, and related procedures; coverage includes pre‑ and post‑operative medical, surgical, and hospital services and medically necessary ambulance transportation to the UnitedHealthcare designated facility. Coverage is subject to prior authorization and must be performed at a UnitedHealthcare designated facility; refer to the member’s Evidence of Coverage/Schedule of Benefits for plan‑specific limits and to the Medical Necessity policy for definitions of investigational or non‑covered services.

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Transplantation Services