2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 62
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 62
Organ/Tissue Transplants
Prior approval requirements:
For the transplants listed below, you must obtain prior approval (see pages 19-22) from the Local Plan, for the procedure and precertification (see page 19) for the facility admission. Prior approval is not required for kidney transplants or for transplants of corneal tissue. Additional benefit requirements apply for the coverage of certain transplants, see pages 66-67.
Prior approval requirements:
For the transplants listed below, you must obtain prior approval (see pages 19-22) from the Local Plan, for the procedure and precertification (see page 19) for the facility admission. Prior approval is not required for kidney transplants or for transplants of corneal tissue. Additional benefit requirements apply for the coverage of certain transplants, see pages 66-67.
- Blood or marrow stem cell transplant procedures
Note: See pages 64-65 for additional requirements that apply to blood or marrow stem cell transplants that are covered only as part of a clinical trial.
- Autologous pancreas islet cell transplant
- Heart-lung transplant
- Heart transplant
- Implantation of an artificial heart as a bridge to transplant or destination therapy
- Intestinal transplants (small intestine with or without other organs)
- Liver transplant
- Lung (single, double, or lobar) transplant
- Pancreas transplant
- Combination liver-kidney transplant
- Combination pancreas-kidney transplant
Covered organ/tissue transplants are listed on page 66. Benefits are subject to medical necessity and experimental/investigational review, and to the prior approval requirements shown above.
In addition, benefits are only available for some transplants (and covered related services) when performed in a Blue Distinction Center or Medicare-Approved Transplant Program. Please see pages 65-66 for more information on the benefits available for the services below. Benefits for implantation of an artificial heart as a bridge to transplant or destination therapy are only available when the facility is designated as a Blue Distinction Center for heart transplants.
Must be performed in a Blue Distinction Center for Transplant:
Must be performed in a Medicare-Approved Transplant Program:
In addition, benefits are only available for some transplants (and covered related services) when performed in a Blue Distinction Center or Medicare-Approved Transplant Program. Please see pages 65-66 for more information on the benefits available for the services below. Benefits for implantation of an artificial heart as a bridge to transplant or destination therapy are only available when the facility is designated as a Blue Distinction Center for heart transplants.
Must be performed in a Blue Distinction Center for Transplant:
- Blood or marrow stem cell transplants
- Heart transplants
- Liver transplants
- Adult single, double or lobar lung transplants
- Adult combination liver-kidney transplants
Must be performed in a Medicare-Approved Transplant Program:
- Heart-lung transplants
- Kidney
- Intestinal
- Adult pancreas transplants
- Pediatric lung transplants
- Adult combination pancreas-kidney transplants