Physicians' services for the following medically recognized organ or tissue transplants are eligible for payment:
Bone Marrow (38230, 38240, 38241)
Cornea (65710-65755)
Heart (33940-33945)
Heart-Lung (33930-33935, 33944)
Islet Cell Autotransplantation (48160)
Kidney (50300-50380, 50547)
Liver (47133-47147)
Lung (32850-32856)
Multivisceral (S2054, S2055)
Simultaneous Pancreas (48550-48556) and Kidney (50300-50380, 50547, S2065)
Small Bowel (44132-44136, 44715-44721)
Small Bowel/Liver (44132, 44133, 44715-44721, 47133, 47143-47147, S2053)
Solitary Pancreas (48550-48556)
The following transplants are considered experimental/investigational and not eligible for payment. A participating, preferred, or network provider can bill the member for the denied service.
- Adrenal to Brain (S2103) - Scientific evidence does not demonstrate the efficacy of adrenal to brain transplantation
- Heterograft (Animal to Human ) - Xenotransplantation from primate donors have not yet received the approval of the FDA for clinical trials
- Islet Cell Allotransplantation (S2102, G0341, G0342, G0343) - Scientific evidence indicates there is a very low success rate with this transplant. Islet cell allotransplantation is still being performed in a clinical trial setting with no long-term outcomes available.
All other transplants not referenced on this policy are considered experimental/investigational and not eligible for payment.
- NOTE:
- See Medical Policy Bulletins S-73, S-116 through S-127, and S-144 for additional information on transplants and PRN references.
The following guidelines are used to process claims for eligible transplant procedures:
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Payment should be made for transplant services performed for a recipient who is a Mountain State member, including the removal of an organ from a living donor or cadaver. Payment is also made for the removal of an organ from a living donor who is a Mountain State member, even though the recipient is not. When only the recipient is a Mountain State member, donor benefits are limited to only those not provided or available to the donor from any other source.
Payment may be made under the recipient's Mountain State coverage only when all other donor sources (e.g., other insurance coverages, government program funding, etc.) have been exhausted. Removal of an organ from a cadaver is payable only when the recipient is a Mountain State member.
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Based on the above guidelines, payment should be made for those services provided by the surgeon for the removal of the organ from the living donor or cadaver for the actual transplant.
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Testing performed to determine donor compatibility is classified as screening because the potential donor is asymptomatic. Liability for potential donor testing lies with the potential donor’s health plan.
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Once the donor has been established, payment may be made for the preoperative testing and medical examination for the donor in preparation for the surgery for the removal of the organ or tissue. The testing (e.g., pathology tests, chest x-ray, and EKG) and medical examination are medically necessary prior to the administration of general anesthesia and/or major surgery.
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Payment may not be made for the purchase price of human organs which are sold rather than donated to the recipient.
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Due to the nature of organ transplant surgery, team surgery is frequently involved. See Medical Policy Bulletin S-12 for additional information.
Coverage for other organ transplants is determined according to individual or group customer benefits. |