Coverage Explanation

Health Net covers the cost of medically necessary, non-experimental and non-investigative organ and stem cell transplants at Medicare-approved, Health Net Transplant Performance Centers (Centers). Service requests are evaluated on a case-by-case basis and must be prior authorized through Health Net or the delegated participating provider group (PPG).

Delegated PPGs use the following procedure for reviewing requests for delegated transplant services:

1. The treating physician or transplant center (requestor) submits a request for transplant services to the delegated PPG Utilization Review Committee.
2. The PPG Utilization Review Committee reviews and informs the requestor of its determination.
3. If Health Net receives a request directly from a treating physician or transplant center for a delegated transplant service, the requestor is referred to the delegated PPG.

The following applies to all non-delegated PPGs

For non-delegated PPG members, all major organ and bone marrow transplants (both allogenic stem cell and autologous stem cell) requests must be submitted by the transplant service provider directly to the Centene Centralized Transplant Unit (CTU) for review. Requests received from the primary care physician (PCP), specialist or PPG will be returned, and the requestor will be informed to have the transplant center submit the request.

A PCP, specialist or non-delegated PPG who identifies a member as a potential candidate for transplant services must provide applicable medical records to a Medicare-approved, Health Net Transplant Performance Center for transplant evaluation.

The Center must submit a prior authorization request for the evaluation to the CTU through the provider portal, or via fax directly to the CTU.

On receipt of a request for a transplant evaluation, the CTU contacts the Center to request any necessary medical records to complete the clinical review. Once complete medical records are received, a review is performed to establish medical necessity. If approved, the Center is notified and provided an authorization number for the evaluation.

Once a member has completed an evaluation and is approved for transplant by the Center, the Center must submit a prior authorization request for listing to the CTU through the provider portal or via fax directly to the CTU.

On receipt of a request for a listing, the CTU contacts the Center to request any necessary medical records to complete the clinical review. Once complete medical records are received, a review is performed to establish medical necessity. If approved, the Center is notified and provided an authorization number.

If the request meets medical necessity, but the requesting transplant center is not a Medicare-approved, Health Net Transplant Performance Center, the member may be redirected to a Medicare-approved, Health Net Transplant Performance Center.

CAR-T cell therapy, corneal transplant, tissue transplant, pancreatic islet cell auto-transplant after pancreatectomy, or parathyroid auto-transplant after thyroidectomy requests must be submitted directly to Health Net.

Refer to the Prescription Drug Program topic for additional information about coverage for immunosuppressive medications following a Medicare-approved transplant.

Health Net's provision of a transplant service at a distant location, farther away than normal community patterns of care for transplant services, depends on the local cost of transplant:

• If a Medicare-approved local transplant provider, within normal community patterns of care for transplants, is not willing to cover a transplant for a Health Net member at a mutually agreed-upon payment rate, then Health Net offers the transplant through an alternative Medicare-approved transplant provider.
• If a Medicare-approved local transplant provider, within normal community patterns of care for transplants, is willing to cover a transplant for a Health Net member at the original Medicare fee-for-service (FFS) rate or at a mutually agreed-upon rate, then, although Health Net may offer the transplant at a distant Medicare-approved location, Health Net allows the member the option of obtaining the transplant services locally.

When providing a covered transplant service at a distant Medicare-approved location, farther away than the normal community patterns of care for transplants, Health Net ensures that the Medicare-approved distant location provides at least the same quality and timeliness of services as local providers of this service. More specifically, the wait time for the transplant at the distant Medicare-approved transplant center location cannot be significantly longer than the wait time within normal community patterns of care.

In any circumstances in which Health Net provides transplant services at a distant location, Health Net may provide reasonable accommodations for the member and a companion while at the distant location depending on the member's Evidence of Coverage (EOC) description.

Health Net offers qualified transplant travel expenditures for Health Net Medicare Advantage members who are sent out of their service area for transplants. Prior authorization is required, and a Health Net case manager determines the set guidelines for lodging based on the member's benefit plan guidelines. Once approved and travel is completed, a member will need to fill out a Medicare Advantage Member Claim Form (PDF) for review and possible reimbursement based on pre-approved services. Providers can refer to the member's EOC or Member Handbook for specific coverage details.