S9976, Lodging, per diem, not otherwise classified
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Evidence that the patient has been accepted for transplantation by an approved transplantation center.
- Proof the patient is actively listed for transplant (OPTN/listing documentation) and, if applicable, documentation of multiple listings.
- Copy or reference to the member’s benefit plan/summary plan description/contract provisions for transplant coverage when applicable.
- Clinical justification that inpatient hospitalization is necessary for donor evaluation and that required tests cannot be safely/effectively performed outpatient.
Key Coverage Criteria
- Coverage considered only for patients accepted for transplantation by an approved transplant center and actively listed for transplant.
- Members listed at more than one transplant hospital (multiple listing) are permitted per OPTN rules (registering at two or more transplant hospitals).
- Coverage includes services from time of admission for or preparation for the transplant, including pre-transplant testing and evaluation (may include tests or office visits prior to the transplant).
- Coverage continues through time of discharge or required follow-up, including outpatient administration of immunosuppressive drugs.
- Services that are medically necessary for the transplant recipient may also be considered medically necessary for the living transplant donor when those services are specifically included as a benefit in the member's benefit plan, summary plan description, or contract.
- Services for the transplant recipient may be considered medically necessary when the recipient has a condition or disorder for which the planned transplant is medically necessary and the recipient has met the transplant selection criteria.
5 Active Policies
SUR703.001, Organ and Tissue Transplantation (General Donor and Recipient Information)
BCBSIL-SUR703.001, Organ and Tissue Transplantation (General Donor and Recipient Information)
BCBSMT-SUR703.001, Organ and Tissue Transplantation (General Donor and Recipient Information)
BCBSNM-SUR703.001, Organ and Tissue Transplantation (General Donor and Recipient Information)
BCBSOK-SUR703.001, Organ and Tissue Transplantation (General Donor and Recipient Information)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.