Subject:
Transplant Donor and Recipient Policy
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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The position of Horizon Blue Cross Blue Shield of New Jersey regarding donor and recipient in transplant procedures.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. All transplant procedures must be ordered by the treating physician.
II. All transplant procedures are subject to contract requirements, limitations and exclusions.
III. Eligibility of the transplantation of a particular organ or bone marrow is determined by the specific policy for the organ or type of marrow transplant (e.g. liver transplant, autologous bone marrow transplantation).
IV. Costs associated with harvesting of organ(s)/tissue(s) from a cadaver donor are not covered when the recipient does not have a contract with Horizon Blue Cross Blue shield of New Jersey (Horizon BCBSNJ). However, when the recipient is covered by Horizon BCBSNJ, costs associated with harvesting of the organ/tissue from a cadaver donor are included in the reimbursement to the transplant center or facility for the eligible transplant procedure paid under the recipient's contract.
V. Horizon BCBSNJ will cover the costs associated with harvesting/procurement of organ/tissue from a living donor (i.e., kidney, bone marrow, peripheral blood stem cells) when both:
A. the recipient is insured by Horizon BCBSNJ and the transplant procedure is eligible contractually and medically necessary; and
B. the donor does not have health insurance benefit that covers the costs associated with organ/tissue donation.
Please note that when the recipient is not insured by Horizon BCBSNJ, donor charges are not eligible. Furthermore, donor charges are not covered in preparation for transplants that are considered by Horizon BCBSNJ either as not medically necessary or investigational.
Covered donor costs include, but are not limited to, the following:
- donor search
- typing (immunologic)
- harvesting of organ/tissue
- processing of the tissue
VI. Harvesting and storage of autologous hematopoietic stem cells is considered medically necessary for:
- a member who is in remission but at high risk for relapse, and the condition being treated is one of the eligible conditions for autologous peripheral blood stem cell transplantation (PBSCT) or autologous bone marrow transplantation; OR
- a member whose current clinical condition qualifies him/her for imminent transplantation (within 30 days), and the condition being treated is one of the eligible conditions for PBSCT or autologous bone marrow transplantation.
VII. Harvesting and storage of allogeneic hematopoietic stem cells or umbilical cord blood is considered medically necessary for:
- a member whose current clinical condition qualifies him/her for imminent transplantation (within 30 days), and the condition being treated is one of the eligible conditions for allogeneic bone marrow transplantation.
VIII. The above provisions may be superseded by contract limitations and specifications regarding transplant donor and recipient benefits.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Transplant Donor and Recipient Policy
Transplant Recipient
Organ Transplant
Donor, Transplant
References:
Not applicable to this policy.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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