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: 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.

When a member has a narrow network plan and there is no in-network transplant facility for the type of transplant needed, call the Provider Helpline, option 3, to be connected to a member of the transplant authorizations team.

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)
  • Spectrum 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

  • Spectrum Health – Bone marrow stem cell (A/P), heart (A), heart/lung (A), kidney (P), lung (A)

Medicare members

LifeTrac Network

For times when care is not available at a facility in the member's plan network, we have partnered with the national LifeTrac® Network of facilities that perform organ and bone marrow transplants. LifeTrac 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

View the LifeTrac Network website, including program guides, facilities map and facility search function

Print a map and listing of the LifeTrac Network transplant facilities and locations