Transplants, solid organ and bone marrow/peripheral stem cell

Applies to:

All plans

Medical policies:

Stem Cell or Bone Marrow Transplantation - 91066

Transplantation of Solid Organs - 91272

End Stage Renal Disease - 91526

Definition:

A transplant is a surgical operation in which a failing or damaged organ or tissue in the human body is replaced with a functioning organ or tissue.

Organ and bone marrow/stem cell transplant authorizations

All transplant services require prior authorization from Priority Health for each of these three steps individually:

1. Evaluation
2. Listing
3. Admission

See the medical policies above and the authorization request forms below for details.

Important notes

• Authorization requirement: Ensure you get authorization beforehand for evaluation, listing and admission.
• Acute admissions: Notify us as soon as possible before the procedure if a member is admitted acutely and requires an evaluation, listing or transplant.
• Evaluation and listing validity: Evaluation is valid for six months and listing for one year. Request an extension before they expire.
• Request process: Transplant facilities typically make the request, but other providers may request authorization for an initial evaluation.
• Submission: These authorizations aren’t available online. Fax authorization requests for any of the three steps using the forms below; send to the fax number at the top of the form.

• Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant form

Note: If your request is for gene and cell therapies, use our Oncology drug request form or Medical drug authorization request form to submit your request.


• Solid Organ Transplant form

In-network transplant facilities

If there is a facility in the member's network that performs the type of transplant needed, HMO, Narrow Networks, Medicare DSNP and Medicaid members must stay in-network.

You must inform POS and PPO plan members that their costs will be higher should they choose to get a transplant from providers outside their network.

Note: Medicare members must go to a Medicare-approved transplant program.

Key: A = Adult; P = Pediatric; A/P = Adult & pediatric 

• Ascension St. John: Kidney (A)
• Corewell Health East – Kidney (A), liver (A)
• Corewell Health West – Bone marrow stem cell (A/P), heart (A), heart/lung (A), kidney (P), lung (A)
• Henry Ford – Bone marrow stem cell (A), heart (A), intestine & multivisceral (A), kidney (A), kidney/pancreas (A), liver (A), liver/kidney (A), lung (A), pancreas (A)
• Karmanos – Bone marrow stem cell (A)
• Mercy Health Saint Mary's, Grand Rapids – Kidney (A) 
• University of Michigan – Bone marrow stem cell (A/P), heart (A/P), kidney (A/P), kidney/pancreas (A), liver (A/P), liver/kidney (A/P), lung (A), pancreas (A)
• VHS Children's Hospital of Michigan: Kidney (P)