Transplants
All solid human organ and bone marrow or stem cell transplants must be certified as medically necessary by Acentra and are subject to the following provisions:
The condition requiring the transplant is life-threatening.
The transplant for the condition is the subject of an ongoing phase III clinical trial or has been approved by FDA.
The procedure follows a written protocol that has been reviewed and approved by an institutional review board, federal agency or other such organization recognized by medical specialists who have appropriate expertise.
The participant is a suitable candidate for the transplant under the medical protocols used by Acentra.
Organ Acquisition Coverage
Benefits are provided for surgical, storage, and transportation expenses incurred and directly related to the donation of an organ or bone marrow/stem cell used in a covered transplant procedure. If any organ or bone marrow/stem cell is sold rather than donated to the participant, no benefits will be payable for the purchase price. Costs related to evaluation and procurement are covered.
Travel Expenses Related to Transplant
Transportation costs of the transplant recipient and one other person to and from the surgery site, as well as reasonable and necessary costs of meals and lodging for the accompanying person, are covered. If the recipient is a minor, reasonable and necessary expenses for the transportation, meals, and lodging of two other accompanying persons are covered. Only those travel expenses incurred at the time of the transplant surgery are eligible for reimbursement. Travel expenses incurred as a result of preoperative and postoperative services are not eligible for reimbursement. The Plan will only reimburse actual travel expenses supported by dated receipts. The amount of reimbursement will not exceed $10,000 for any single transplant episode. Dated receipts must be submitted to BCBSMS to qualify for reimbursement.
Living Donor Coverage
The following chart summarizes when benefits are available for an organ or bone marrow/stem cell transplant from a living donor:
If... | Then... |
|---|---|
Both the recipient and the donor are participants | Donor's benefits will be applied to the recipient's Plan benefit. |
Only the recipient is a participant | Donor gets Plan benefits unless covered by another plan. Benefits provided will apply to the recipient's Plan. |
Only the donor is a participant | No benefits are provided. |
Benefits for the following services are provided to the donor:
Search for matching bone marrow, or organ.
Transportation to and from the surgery site.
Organ or bone marrow/stem cell removal, withdrawal and preservation and hospitalization.
Bariatric Surgical Services
Benefits for bariatric surgery are only provided for participants 18 years or older and are limited to one surgery per lifetime paid for by the Plan, and must be authorized by Acentra. Benefits for these services are provided only when the facility is an American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE). Participants must agree to participate in a medically supervised treatment plan for at least one-year post surgery. Bariatric surgery for morbid obesity will only be considered medically necessary when ALL of the following are met:
Consent to a multidisciplinary health evaluation at a BSCOE. Page 17| Mississippi's State and School Employees' Life and Health Insurance Plan Document – Revised 1/1/2024
Must meet one or more of the following clinical criteria: Presence of severe obesity that has persisted for at least the last two years (24 months) as documented in clinical records, defined as one or more of the following: o Body mass index (BMI) exceeding 40; or o BMI greater than 35 in conjunction with any one or more of the following severe comorbidities: Clinically significant obstructive sleep apnea Coronary heart disease Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management) Type 2 Diabetes Mellitus
Participant must meet one or more of the following criteria: o Medically-supervised nutrition and exercise program o Multidisciplinary surgical preparatory regimen
Medically supervised nutrition and exercise program Participant must have participated in two or more medically-supervised nutrition and exercise programs (including dietitian consultation, low calorie diet, increased physical activity and behavior modification, Weight Watchers®, the Atkins Diet®, the South Beach Diet®, or Sugar Busters®), documented in the medical record at each visit. This medically-supervised nutrition and exercise program must meet ALL of the following criteria:
Participation must be documented in the medical record. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other provider. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of clinician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For participants who participate in a medically administered nutrition and exercise program (e.g., MediFast®, OptiFast®), program records documenting the participant's participation and progress may substitute for provider medical records.
Nutrition and exercise program must be supervised and monitored by a clinician working in cooperation with dietitians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote).
Nutrition and exercise program(s) must be for a cumulative total of six months (180 days) or longer in duration and occur within two years before surgery, with participation in one program of at least three consecutive months. Precertification may be made before completion of nutrition and exercise program as long as six months of cumulative participation in nutrition and exercise program(s) is completed before the date of surgery.
Multidisciplinary surgical preparatory regimen Within six months before surgery, the participant must participate in an organized multidisciplinary surgical preparatory regimen of at least three months (90 days) duration meeting ALL of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the participant's ability to comply with postoperative medical care and dietary restrictions:
Behavior modification program supervised by qualified professional.
Consultation with a dietitian or nutritionist. Mississippi's State and School Employees' Life and Health Insurance Plan Document – Revised 1/1/2024 | Page 18
Documentation in the medical record of the participant's participation in the multidisciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the participant, and the physician's assessment of the participant's progress at the completion of the multidisciplinary surgical preparatory regimen.)
Exercise regimen (unless contraindicated) to improve pulmonary reserve before surgery, supervised by exercise therapist or other qualified professional.
Program must have a substantial face-to-face component (must not be entirely delivered remotely).
Reduced-calorie diet program supervised by dietitian or nutritionist.
For participants who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, clearance must be provided via formal psychiatric or doctorate level psychology evaluation by an individual with experience in the evaluation of bariatric surgery patients.
Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.
Sleep Disorders
Unattended home sleep studies are covered subject to medical necessity and only when provided by a network sleep center which has met the American Academy of Sleep Medicine (AASM) Standards for Accreditation.
Temporomandibular Joint Syndrome (TMJ)
Benefits for surgery and diagnostic services of the temporomandibular/craniomandibular joint are provided, up to a lifetime maximum benefit of $5,000. Benefits are not provided for physical therapy, orthodontics, dentures, occlusal reconstruction, or for crowns or inlays.