Pending Policies - Surgery
Organ and Tissue Transplantation (General Donor and Recipient Information)
*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*
NOTE 1: For HCSC medical policies on specific solid organ transplantation see SUR703.003 through SUR703.010 and SUR703.013 through SUR703.014.
NOTE 2: For HCSC medical policies on stem cell transplantation (including bone marrow, peripheral blood, and umbilical cord blood as a source of stem cells) as a treatment of specific conditions and/or disorders see SUR703.002, SUR703.029 through SUR703.047, and SUR703.050.
NOTE 3: Only those patients accepted for transplantation by an approved transplantation center and actively listed for transplant should be considered for transplant coverage and determination of medical necessity.
The member’s benefit plan, summary plan description or contract for transplant coverage provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Transplant Services Covered Time Span will be Defined from the:
• Time of admission for or preparation for the transplant, including testing and evaluation, which may include tests or office visits prior to the actual transplant, THROUGH THE
• Time of discharge or at the end of the required follow-up, including the administration of immunosuppressive drugs on an outpatient basis.
For the Purposes of this Policy, the Following Terminology is Defined as Follows:
• A “Living Transplant Donor” is a living person who donates a solid organ for transplantation (such as, kidney or portions [segments] of lung, liver, pancreas, or intestines;
• A “Deceased Transplant Donor” is person who has suffered brain death or cardiac death and is maintained on life support measures, and from whom a solid organ has been harvested for the purpose of transplantation (such as, heart, heart/lung, lung, liver, kidney, pancreas, kidney/pancreas, or intestines);
• A “Cadaver Transplant Donor” is a person who has suffered brain death or cardiac death, IS NOT maintained on life support measures, and is unable to donate a solid organ for transplantation; however, other tissue may be harvested for transplantation (such as, cornea, sclera, bone, tendons, ligaments, cartilage, heart valves, veins, and skin tissues). NOTE 4: In the literature, cadaveric kidney donation is equivalent to deceased kidney donation. Utilization of “cadaveric kidney transplantation” terminology is being replaced with “deceased donor kidney or renal transplantation”.
Living Transplant Donor (refer to definition above):
Services that may be considered medically necessary for the TRANSPLANT RECIPIENT may also be considered medically necessary for the TRANSPLANT DONOR, only when they are specifically included as a benefit or covered service in the member's benefit plan, summary plan description or contract.
Cadaver Transplant Donor (refer to definition above):
Services for a cadaver donor are never covered as the donor’s benefit period, benefit plan or contract terminates at the time of the donor’s death.
The following services may be considered medically necessary IF the recipient has a condition or disorder for which the planned transplant is considered medically necessary and has met the transplant selection criteria:
• Hospitalization for a covered transplant;
• Evaluation tests requiring hospitalization to determine the suitability of both potential and actual donors (tissue typing), when such tests cannot be safely and effectively performed on an outpatient basis;
• Hospital services, such as room and board, nursing services, surgical rooms, supplies, use of equipment, special care units (coronary and intensive care or private rooms for isolation purposes), and ancillary services;
• Physicians' services for surgery, technical assistance, administration of anesthetics, and medical care;
• Acquisition or harvest, preparation, transportation (within the United States and Canada), and short-term storage of the organ or tissue (see “Special Comment on Organ and/or Tissue Storage” below), for imminent utilization (as storage may be an exclusion under some member's contracts) of the organ or tissue;
• Diagnostic services; AND
• Pharmaceuticals that require a prescription to dispense by federal law.
Special Comment on Organ and/or Tissue Storage: Storage implies temporary, short-term, imminent storage, up to 60 days after harvesting, for use in a patient already approved for an imminent transplant.
Additional Elements of Organ and Tissue Transplantation:
The following elements are usually a part of the organ and tissue transplantation process AND may be non-covered services or benefits. These elements include, but are not limited to:
• Those services listed above when the cost is reimbursed or funded by a governmental, foundation, or charitable grant;
• Organs sold rather than donated to the recipient;
• Donor search costs, including registries and potential donor typing costs;
• Procedures, services, supplies, equipment and/or room use for the procurement or harvesting of organs or tissues from a living or deceased donor, IF the donor was covered by another commercial health care carrier or self-funded health care plan (not Health Care Services Corporation [HCSC]);
• An organ or tissue transplant from a species other than human, such as monkey bone marrow cells;
• An artificial organ or tissue, whether temporary or permanent (except in cases where cardiac mechanical assist devices [Refer to HCSC medical policy SUR707.017 – Ventricular Assist Devices and Total Artificial Hearts] are used as a bridge to transplantation or as destination therapy OR in cases of corneal transplantation);
• Living and/or travel expenses, including tourism activities, of the living donor, recipient, and family members of the living donor or recipient;
• Physician and hospital expenses related to maintenance of life for purpose of organ donation (This includes the travel time and related expenses required by a provider.);
• Any services provided to any individual who is not the recipient or actual donor; AND,
• Long term storage costs for future possible anticipated transplantation, not scheduled or of time certain.
Transplantation is the transfer of living tissues or cells from a donor to a recipient, with the intent of maintaining the functional integrity of the transplanted tissue or cells in the recipient. The success of organ and tissue transplantation has been attributed to:
• New, more selective immunosuppressants;
• Improved histocompatibility typing and surgical technique;
• Better patient selection;
• Earlier operative intervention;
• Earlier and more accurate detection of rejection episodes;
• A better understanding of the immune rejection mechanism.
Table 1. Transplants are Categorized by Site and Genetic Relationship Between Donor and Recipient
If the Organ or Tissue Graft is:
Then the transfer is:
To an anatomically normal recipient site, such as in a heart transplant.
To an anatomically abnormal site, such as the transplantation of a kidney into the iliac fossa (within the pelvic bony structure) of the recipient.
Of one's own tissue from one location to another, such as a bone graft to stabilize a fracture.
Syngeneic Graft (isograft),
A graft between identical twins.
A graft between genetically dissimilar members of the same species, such as bone marrow- or stem-cells from a human donor.
A graft between members of different species, such as bone marrow cells from a monkey donor to a human recipient.
Solid organs that can be transplanted include the heart, lung(s), kidney(s), pancreas, liver, and small intestine.
Tissue transplantation consists of cells and fluids, as well as body parts. These include, but are not limited to, hand(s), cornea(s), skin graft (including face replant or transplant), penis, Islets of Langerhans, hematopoietic stem-cells, blood transfusions or blood parts transfusion, blood vessel(s), heart valve, and bone.
Tissue compatibility is the degree of similarity between the genetically determined tissue antigens of the donor and the recipient. Histocompatibility studies or tissue typing are completed before the transplantation to identify human white blood cell “antigens” and to minimize the antigenic differences between the donor and the recipient.
Immunosuppressive drugs are used to control organ rejection caused by the remaining antigenic differences due to imperfect donor-recipient matching. They are primarily responsible for the present success of clinical transplantation. However, these drugs suppress ALL immunologic reactions, making overwhelming infection the leading cause of death in transplant recipients.
The policy was originally created in May 1990 and was updated regularly with literature searches of the MedLine database. The most recent search was performed in February 9, 2017. No articles were identified that would change the coverage position of this medical policy.
Coverage issues include contractual and plan benefits, limitations and exclusions regarding donors and recipients. This includes whether donor and recipient have the same health care insurer, or if one has health care coverage and one does not, or if one has a managed care/health maintenance organization (HMO) coverage and the other has coverage with a commercial health care insurer, or if both have different managed care/HMO coverage.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
S9975, S9976, S9977
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM manual
ICD-9 Procedure Codes
Refer to the ICD-9-CM manual
ICD-10 Diagnosis Codes
Refer to the ICD-10-CM manual
ICD-10 Procedure Codes
Refer to the ICD-10-CM manual
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Human Organ Transplantation. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Review (1988 August):351-65.
2. WebMD SAM Medicine - Organ Transplantation. Scientific American Medicine (1991 September) Chapter V:1-31. Available at <http://www.ramex.com> (accessed – 1999 April 1).
3. Berkow R, Fletcher AJ, eds. The Merck Manual - 17th edition. New Jersey: Merck & Co., Inc. (1992):346-54.
4. Human Organ and Tissue Transplantation Considered Eligible for Coverage. Chicago, Illinois: Blue Cross Blue Shield Association Uniform Medical Policy Manual (1994 March) Surgery 3.0-3.2.
5. UNOS – Partnering with Your Transplant Team. Health Resources and Services Administration, U.S. Department of Health and Human Services (2008):1-107. Available at <http:www.unos.org> (accessed on February 11, 2015).
6. Kidney Transplant. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2016 December) Surgery 7.03.01.
|4/15/2018||Reviewed. No changes.|
|4/15/2017||Document updated with literature search. Coverage unchanged. The following was added: “NOTE 3: Only those patients accepted for transplantation by an approved transplantation center and actively listed for transplant should be considered for transplant coverage and determination of medical necessity.”|
|3/1/2016||Reviewed. No changes.|
|5/1/2015||Document updated with literature search. Coverage unchanged.|
|12/1/2013||Document updated with literature search. Coverage unchanged.|
|4/1/2010||Revised/updated entire document. Policy contains general information on transplantation of solid organs as well as blood and tissue. Policy addresses general services for donor and recipient. This policy is no longer scheduled for routine literature review and update.|
|5/15/2007||Revised/updated entire document|
|6/1/2001||CPT/HCPCS code(s) updated|
|1/1/2000||Revised/updated entire document|
|4/1/1999||Revised/updated entire document|
|5/1/1996||Medical policy number changed|
|4/1/1994||Revised/updated entire document|
|10/1/1993||Revised/updated entire document|
|4/1/1993||Revised/updated entire document|
|5/1/1990||New medical document|
|Title:||Effective Date:||End Date:|
|Organ and Tissue Transplantation (General Donor and Recipient Information)||04-15-2018||04-14-2020|
|Organ and Tissue Transplantation (General Donor and Recipient Information)||04-15-2017||04-14-2018|
|Organ and Tissue Transplantation (General Donor and Recipient Information)||03-01-2016||04-14-2017|
|Organ and Tissue Transplantation (General Donor and Recipient Information)||05-01-2015||02-29-2016|
|Organ and Tissue Transplantation (General Donor and Recipient Information)||12-01-2013||04-30-2015|
|Organ and Tissue Transplantation (General Donor and Recipient Information)||04-01-2010||11-30-2013|
|Information on Organ and Tissue Transplantation||05-15-2007||03-31-2010|
|Information on Organ and Tissue Transplantation||01-01-2000||05-14-2007|