Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 09|01|2022 POLICY LAST UPDATED: 05|20|2025

Overview This is an administrative policy that outlines the services that are covered when a member has a solid organ transplant at a facility greater than 50 miles from their home.

This policy is applicable to Medicare Advantage Plans only

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
No preauthorization needed
POLICY STATEMENT Medicare Advantage Plans Travel and lodging expenses noted in this policy are covered benefits only when associated with approved transplantation services and the criteria for reimbursement are met:

• Criteria for Travel and Accommodation Reimbursement Limited to Transplant Period which is defined as 5 days prior to the transplant and ends when the member returns home after discharge from inpatient (Skilled Nursing or Rehabilitation) Facility

• Travel and Accommodations for follow up visits are excluded from this benefit • The maximum amount payable for travel and lodging services related to the initial solid organ transplant is limited to $10,000.00 per Transplant.

• Transplantation service is performed at a Center for Medicare & Medicaid Services' Medicare-approved provider that is greater than 50 miles from the member’s home.

• Applies to the patient and 1 companion or 2 companions or caregivers for dependents traveling to and from home/lodging to the approved transplant facility only. (Any additional miles during the stay are ineligible.) • Automobile expenses (mileage and gas) will be reimbursed at the IRS-medical mile approved rate in effect on the date of travel which can be found at www.irs.gov. • Lodging includes hotels, motels, extended stay facilities or apartments. It is not a reimbursable expense if staying with family or friends in the area. • Reimbursement of lodging will be based up to the per diem rate for lodging specified by the US General Service which is available at available at: www.gsa.gov. • Airfare reimbursement is limited to coach or economy fares.
• Receipts are required to be submitted for airfare and lodging only. • If member is unable to travel home via private transportation due to bed confined status, then refer to the ambulances policies in the related policy section. • All requests for reimbursement of covered services must be submitted within 180 days from discharge using the attached form.

Claim Submission Form for Travel Services

The following lists of services, including but not limited to, are excluded from coverage as part of this benefit:
• Alcohol • Car rental • Clothing • Entertainment (i.e. movies or rentals, visits to museums, additional mileage for sightseeing, compact discs, games etc.) • Expense for persons other than the patient and his/her covered companion or caregiver • Expenses for lodging when member or companion is staying with a relative or friend Payment Policy | Transplants – Travel and Accommodations for Medicare Advantage Plans

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• Gasoline • Groceries (i.e. grocery stores, Walmart, K-Mart, Target, etc.) • Laundry service/supplies • Non-Legible receipts (i.e. lodging • Paper products (i.e. paper plates, paper towels • Parking fees incurred other than at hotel/motel or hospital • Personal hygiene items (i.e. toothbrush, deodorant, etc.) • Personal service (i.e. child care, house sitting, kennel care, etc.) • Shoe/slippers/robes • Souvenirs (i.e. t -shirts, sweatshirts, toys, etc.) • Telephone bills/calls/phone cards • Tobacco • Valet Parking • Limo service • Gym fees • Wi-Fi • Spa • Any service that is an additional charge to the room charge • Additional mileage for sightseeing or visits to friends/relatives • Any other service not listed in this policy is excluded from reimbursement

COVERAGE Please refer to the appropriate Evidence of Coverage for applicable Transplant Travel benefits/coverage.

BACKGROUND As noted by CMS in the Medicare Managed Care Manual - Chapter 4, section 10.11, every Medicare Advantage (MA) plan must provide all original Medicare services to its enrollees. For coordinated care plans, in-network transplant services may be provided outside of the plan service area if the services are accessible and available to enrollees, and that service delivery is consistent with community patterns of care for original Medicare beneficiaries who reside in the same area.

MA plans, for reasons of cost (as explained below), may wish to provide a required original Medicare transplant service at a distant location (further away than the normal community patterns of care for that service), even though provision of the service is available locally (within the service area), consistent with community patterns of care for original Medicare beneficiaries who reside in the service area.

The MA plan’s provision of transplant services at a distant location, farther away than the normal community patterns of care for transplant services, depends on the local cost of transplants:
• If the local providers of transplants, within the normal community patterns of care for transplants, are not willing to cover transplants for MA enrollees at a mutually agreed upon payment rate, then the MA plan must offer transplants through alternative transplant providers.

• If the local providers of transplants, within the normal community patterns of care for transplants, are willing to cover transplants for MA enrollees at the original Medicare rate or at a mutually agreed upon rate, then, although the MA plan may also offer transplants at a more distant location, the MA plan must allow enrollees the option of obtaining transplant services locally.

When providing an original Medicare service at a more distant location, farther away than the normal community patterns of care for transplants, the MA plan must ensure that the distant location provides at least the same quality and timeliness of services as at the local providers of this service. More specifically, the transplant center at the distant location must be a Medicare-eligible transplant provider and the waiting time for the transplant should not be significantly longer than the waiting within the normal community patterns of care.
In any circumstance in which an MA plan provides transplant services at a more distant location, the MA plan must:
• Provide reasonable transportation for the enrollee and a companion to the distant facility; and • Provide reasonable accommodations for the enrollee and a companion while present in the distant location for medical care.

CODING Not applicable

RELATED POLICIES Ambulance Services- Ground Ambulance Services- Air and Water

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

PUBLISHED Provider Update, June 2025 Provider Update, November 2023 Provider Update, November 2022 Provider Update, April 2020 Provider Update, April, 2018
Provider Update, March 2017 Provider Update, March 2016

REFERENCES:

1. Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary Protections, Section 10.11 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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