Covered Transplants

A transplant recipient who is eligible under this plan and who has satisfied the waiting period is eligible for the following transplants, subject to the conditions and limitations described below:

• Heart.
• Heart/lung (combined).
• Kidney.
• Kidney/pancreas (combined).
• Islet cell.
• Lungs (single/bilateral/lobar).
• Liver.
• Small bowel.
• Small bowel/liver/multivisceral.
• Cornea.
• Pancreas.
• Donor stem cells can be collected from either the bone marrow or the peripheral blood. Hematopoietic stem cell support may involve the following donors, i.e., either autologous (self-donor), allogeneic (related or unrelated donor), syngeneic (identical twin donor), or umbilical cord blood only as specified below.
• Other transplants determined by this plan to be covered since this plan booklet was printed.

With regard to autologous stem cell support, syngeneic stem cell support, and high dose chemotherapy associated with autologous stem cell support or syngeneic stem cell support, coverage is available for treatment of the following malignancies or conditions:

• Non-Hodgkin’s lymphoma.
• Hodgkin’s lymphoma.
• Neuroblastoma.
• Acute lymphocytic or non-lymphocytic leukemias.
• Germ cell tumors.
• Multiple myeloma.
• Ewing’s sarcoma.
• Wilms’ tumor.
• Other malignancies or conditions determined by this plan to be a covered benefit since this plan booklet was printed.

Autologous stem cell support, syngeneic stem cell support, and high dose chemotherapy associated with autologous stem cell support or syngeneic stem cell support for conditions other than those listed above will not be covered.

With regard to allogeneic stem cell support and high dose chemotherapy associated with allogeneic stem cell support, coverage is available for treatment of the following malignancies or conditions:

• Acute lymphocytic or non-lymphocytic leukemias.
• Chronic myelogenous leukemia.
• Aplastic anemia.
• Hodgkin’s lymphoma.
• Non-Hodgkin’s lymphoma.
• Severe combined immunodeficiency (not AIDS).
• Wiskott-Aldrich syndrome.
• Infantile malignant osteopetrosis.
• Neuroblastoma.
• Homozygous beta-thalassemia.
• Myelodysplastic syndromes.
• Mucopolysaccharidosis.
• Mucolipidosis.
• Multiple myeloma.
• Sickle cell anemia.
• Kostmann’s syndrome.
• Leukocyte adhesion deficiencies.
• X-linked lymphoproliferative syndrome.
• Megakaryocytic thrombocytopenia.
• Other malignancies or conditions determined by this plan to be a covered benefit since this plan booklet was printed.

Allogeneic stem cell support and high dose chemotherapy associated with allogeneic stem cell support for conditions other than those listed above will not be covered.

Cord Blood Stem Cells

Transplantation of cord blood stem cells from related or unrelated donors is considered medically necessary when the recipient is a child, adolescent or young adult with an appropriate indication for allogeneic bone marrow transplant but without a hematopoietic stem-cell donor. Collection and storage of cord blood from a neonate is considered medically necessary when an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the possible need for allogenic transplant. Preauthorization with the medical review agency is required (non-Medicare individuals only).

Prophylactic collection and storage of cord blood from a neonate is not considered medically necessary when proposed for unspecified future use as an autologous stem cell transplant in the original donor, or for unspecified use as an allogeneic stem cell transplant in a related or unrelated donor.

Donor Benefits

Donor procurement costs are available up to a maximum of $25,000 per transplant if the transplant recipient is covered for the transplant under this plan. If procurement expenses exceed this $25,000 per transplant procurement maximum, this plan will not pay the additional costs. Donor procurement benefits are limited to selection, removal of the organ or tissue, storage, transportation of the surgical harvesting team and the organ or tissue, and such other medically necessary procurement costs as determined by this plan. Donor benefits are charged against the recipient’s annual plan maximum. Donor benefits are not provided when they are available through another health care plan, when the donor is eligible under this plan and the recipient is not, or for donor and procurement services and costs incurred outside the United States, unless specifically approved by the Trust Office.

Key Point

Donor benefits are not provided when they are available through another health care plan, when the donor is eligible under this plan and the recipient is not, or for donor and procurement services and costs incurred outside the United States, unless specifically approved by the Trust Office.

Benefits are not provided for:

1. Nonhuman, artificial or mechanical transplants.
2. Experimental or investigational services or supplies as defined by this plan.
3. Services in a facility not approved by this plan.
4. Stem cell support and high dose chemotherapy associated with stem cell support, except as specified by this plan.
5. Services and supplies for the donor when the donor benefits are available through other group coverage.
6. Expenses when government funding of any kind is provided.
7. Expenses when the recipient is not covered under this plan.
8. Lodging, food or transportation costs, unless specifically provided under this plan.
9. Donor and procurement services and costs incurred outside the United States, unless specifically approved by the Trust Office.
10. Any services or supplies relating to the transplant if furnished before the recipient has met the transplant waiting period described above.
11. More than one retransplant (subject to the limits specified above) if the transplant was not successful.

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