Transplants

Transplants are a limited benefit. Transplants, excluding corneal transplants, require prior authorization for all beneficiaries (excluding those with other health insurance).

Services and supplies related to a transplant are also covered, including:

• evaluation of the candidate for transplantation
• pre- and post-transplant outpatient and inpatient hospital services including medications
• transportation of the donor organ
• donor costs*

Nonmedical expenses such as living expenses outside of the hospital including hotels, meals and transportation of an organ donor are not a covered benefit.

Transplants are not a covered benefit if the patient has another existing illness that would jeopardize the success of the transplant or if the transplant is not a proven treatment for the beneficiary’s condition.

The following are a few transplants that may be a covered benefit (this list is not all inclusive):

• corneal transplant (keratoplasty)
• heart transplant
• intestinal transplant
• kidney transplant
• liver transplant
• lung transplant
• pancreas transplant
• stem cell transplant

*Donor costs are covered when the donor or recipient is a TRICARE beneficiary. If the donor is not a TRICARE beneficiary, coverage is limited to those services directly related to the transplant procedure itself and do not include any medical care costs related to other treatment of the donor, including complications.

If covered, the setting where the services are provided will determine costs; outpatient office setting, ambulatory surgery setting or inpatient hospital setting.

Reimbursement

TRICARE will pay certified transplant centers (CTCs) a prospective payment rate to get the organs. The CTCs must develop two Medicare Standard Acquisition Charges (SACs) based on reasonable and necessary organ acquisition costs:

1. A Medicare SAC for acquiring a living donor organ (estimated average charge for services provided to living donors and recipients of living donor organs)
2. A Medicare SAC for acquiring a cadaveric donor organ (estimated average charge for procuring cadaveric organs combined with expected costs of acquiring cadaveric organs from other sources)

The SACs cover total costs for getting either live or cadaver organs. Solid organ procurement costs must be billed separately with revenue code 081X and Healthcare Common Procedure Coding System (HCPCS) code S2152 to be eligible for reimbursement.