*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare^SM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure

Transportation is the movement of humans from one location to another. Modes of transportation include automobile, bus, rail and/or air. Lodging refers to a temporary place to stay/sleep.

Policy Statement

Coverage will be provided for transportation and/or lodging related to a transplant when the criteria and guidelines shown below are met.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination. Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD); and
• General coverage guidelines included in Original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (EOC), the EOC always governs the determination of benefits.

Indications for Coverage

1. Transportation and lodging are covered for transplants that have prior approval by the Plan.
2. Community pattern of care is based on the provider and type of transplant service they offer as well as where the member lives. If the provider is located at a distant location (farther away than the normal community pattern of care for the type of transplant), even if the service is available locally (within the service area) and is consistent with care for Original Medicare beneficiaries who reside in the service area. The service would be considered outside of the normal community patterns of care.

In any circumstance in which an MA plan provides transplant services at a more distant location (outside of the normal community pattern of care), the MA plan must:

1. Provide reasonable transportation for the enrollee and a companion to the distant facility; and
2. Provide reasonable accommodations for the enrollee and a companion while in the distant location for medical care

Benefit Period and Limits Defined

1. The benefit period for a covered transplant begins five (5) days prior to the transplant and extends through the member’s transplant episode of care, not to exceed one (1) year from the date of the transplant procedure.
2. The maximum amount payable for allowed transportation and lodging services, which includes costs for both you and your companion, related to an approved covered transplant is $10,000 per transplant. For the travel benefit, two or more organs (i.e., heart-lung, kidney-pancreas) transplanted during one hospitalization are considered one transplant and reimbursement is subject to the $10,000 combined maximum for the episode of care.
3. Travel and lodging expenses are covered for the recipient (exclusive of the inpatient hospital admission) and one eligible companion. Companions may be a spouse or partner, family member, legal guardian or any person not related to the member but actively involved in the member’s care.

Special Note: All transportation and/or lodging requests will need to be discussed with a Medical Director before a determination can be made.

When Coverage Wil Not be Approved

Items not directly related to transportation and lodging expenses are not reimbursable. They include but are not limited to:

• Air Miles
• Alcoholic beverages or tobacco products
• Car maintenance
• Car rental club memberships
• Cards, stationary, stamps
• Clothing
• Entertainment (i.e., cable television, books, magazines, movie rentals, movie subscriptions, etc.)
• Extended parking at the airport
• Fines or traffic tickets, court costs or other loss or damage resulting from traffic violations or incidents
• Flowers
• Household products (i.e., cleaning supplies, kitchen utensils, paper products, etc.)
• Household utilities, including cell phone charges, maid services, pet sitter services, babysitter services, house sitter, day care and Wi-Fi
• Laundry services and/or dry cleaning
• Loss of money or loss/damage to luggage, clothing or other items
• Meals for member and approved companion (Note: meals for the member during an inpatient hospital stay are covered as part of the inpatient hospital care)
• Parking fees and tolls
• Pet services, including but not limited to pet kennel, boarding, pet sitting, pet care items and pet transportation fees
• Postage
• Ride services (i.e., taxi, Uber, Lyft, etc.)
• Security deposits
• Toiletries
• Toys
• Traveler check fees
• Valet parking
• Vehicle expenses (maintenance (including oil changes, tires, etc), deposits, repairs, insurance and mileage
• Any item not specifically listed as covered

Billing/ Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in the section does not guarantee reimbursement.

Applicable Codes: N/A

The Plan may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

References

1. Medicare Managed Care Manual- Chapter 4- Benefits and Beneficiary Protections Section 10.11 Transplant Services. Issued on 4/22/2016. Accessed via https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf on 8/1/2024.
2. Transplant Program Application Requirements accessed at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/transplantfinallawandreg.pdf on 8/1/2024.
3. Blue Cross Blue Shield of Rhode Island Payment Policy: Transplants-Travel and Accommodations for Medicare Advantage Plans; effective date: 9/1/2022. Viewed at https://www.bcbsri.com/providers/sites/providers/files/policies/2023/09/2023%20Transplants%20Travel%20and%20Lodging%20for%20Medicare%20Advantage%20Plans.pdf on 8/1/2024.

Policy Implementation/Update Information

Revision Date: August 19, 2024: Policy created

Approval Dates

Medical Coverage Policy Committee: August 19, 2024

Physician Advisory Group Committee: November 19, 2024

Quality Improvement Committee: December 12, 2024