Transplants, solid organ and bone marrow/peripheral stem cell
Applies to:
All plansMedical 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: Evaluation, listing, and admission. See the medical policies above and the authorization request forms below for details.
Normally, transplant facilities make the requests, but other providers may request authorization for the initial evaluation.
Authorizations are not available online. Fax requests for authorization of any one of the three steps using these forms. The fax number is on the top of the form.
In-network transplant facilities
If there is a facility in the member's network that performs the type of transplant needed, HMO 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.
Key: A = Adult; P = Pediatric; A/P = Adult & pediatric
HMO, POS, PPO and individual MyPriority® plan members
- Beaumont – Kidney (A), liver (A)
- Karmanos – Bone marrow stem cell (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)
- Corewell Health – Bone marrow stem cell (A/P), heart (A), kidney (P), lung (A)
- Mercy Health Saint Mary's, Grand Rapids – Kidney (A)
Employer group HMO, POS, and PPO plan members only
- 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)
Medicaid, Healthy Michigan Plan and MIChild members
- Corewell Health – Bone marrow stem cell (A/P), heart (A), heart/lung (A), kidney (P), lung (A)
Medicare members
- You must go to a Medicare-approved transplant program.
Emerging Therapy Solutions
For times when care is not available at a facility in the member's plan network, we have partnered with the national Emerging Therapy Solutions Network of facilities that perform organ and bone marrow transplants. Emerging Therapy Solutions ensures that patients have access to quality care from experienced transplant centers. They evaluate each participating facility based on:
- Accreditation
- Dedication to research
- Volume of procedures done annually
- Surgical team experience
- Survival rates