BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy for Human Organ and Tissue Transplantation

PURPOSE

To establish a basis for determining the medical necessity of human organ and tissue transplantation.

DESCRIPTION

Human organ and tissue transplants are defined as the transfer of a human organ or tissue from one person to another or the transferring of tissue from its normal position to another site.

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness for human organ and tissue transplantation.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

********* THE FOLLOWING POLICIES HAVE BEEN *********

REVIEWED. PLEASE REFER TO THE POLICY

********* TO DETERMINE MEDICAL APPROPRIATENESS. *********

DIAGNOSTICS:

• Laboratory Tests for Heart Transplant Rejection

• Post Heart Transplant Endomyocardial Biopsy

THERAPEUTICS:

• Allograft Anterior Cruciate Ligament (ACL) Reconstruction

• Autologous Chondrocyte Implantation (ACI)

• Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem Cell Transplant

• Hair Transplantation

• Hematopoietic Stem Cell Transplant for Breast Cancer

• Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults

• Hematopoietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors

• High Dose Chemotherapy with Autologous Stem-Cell Transplant for Primary Amyloid Light-Chain (AL) Amyloidosis

• High Dose (Myeloablative) Chemotherapy with Bone Marrow, Peripheral Stem Cell, or Cord Blood Transplant for Hematopoietic Stem Cell Support

• Implantable Ventricular Assist Devices (VAD) and Total Artificial Hearts (TAH)

• Meniscal Allografts and Collagen Meniscus Implants

• Nonmyeloablative Allogeneic Stem Cell Transplantation (Reduced Intensity Stem Cell Transplant) for Treatment of Malignancy

• Osteochondral Allografting

• Osteochondral Autografting (OCG)

• Pancreas / Pancreas-Kidney / Pancreatic Islet Cell Transplantation

• Small Bowel / Small Bowel-Liver / Multivisceral Transplantation

• Tandem High Dose Chemotherapy with Hematopoietic Stem Cell Support

ORIGINAL EFFECTIVE DATE:  4/1980

MOST RECENT REVIEW DATE:  6/22/2011

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.