U.S. Office of Personnel Management www.opm.gov - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

Federal Employees Health Benefits Program

This carrier letter transmits an updated list of organ/tissue transplant benefits for plan brochures, as was addressed in this year's Call Letter (Carrier letter 2006-09) dated April 4, 2006. Attached are three tables which include specific lists of diagnoses and/or conditions for organ/tissue transplants. The tables are labeled as follows:

• Table 1 - OPM's required list of covered organ/tissue transplants
• Table 2 - Recommended organ/tissue transplants when received as part of a clinical trial
• Table 3 - Recommended organ/tissue transplants

OPM based its organ/tissue coverage requirements on the Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Committee's review of the scientific literature and accepted standards of practice within the oncology community. The BCBSA Committee is comprised of a group of clinical physician experts and also includes clinical experts from the Kaiser Permanente Foundation. OPM has included additional organ/tissue transplant recommendations from an external review by The National Cancer Institute of the National Institutes of Health.

The OPM minimum level of coverage for the organ/tissue transplants appears in Table 1. Each plan must specify whether or not it will provide coverage in 2007 for the organ/tissue transplants that appear on Tables 2 and 3 and return this information with its 2007 benefit proposal. Plans may cover additional organ/tissue transplants that do not appear on the tables. If your Plan covers an organ/tissue transplant that does not appear on the tables, please submit the additional transplant(s) and include the specific diagnosis and disease staging in the 2007 benefit proposal.

Plans must update their 2007 brochures fully to reflect specific organ/tissue transplant coverage including the corresponding diagnosis and disease staging. Plans must base their organ/tissue transplant coverage decisions strictly on the list of covered diagnoses and disease staging as it appears in their 2007 brochure. Plans may continue to fully review solid organ transplants for medical necessity. However, plans must limit their review for all other transplants to the diagnosis and staging of the illness (e.g., acute, chronic, etc.). If plans deny coverage, it must be strictly a contractual denial (e.g., diagnosis and/or staging of the illness is not listed as covered). Plans may not deny organ/tissue transplants as experimental/investigational. The experimental/investigational exclusion will no longer apply to organ/tissue transplants under the FEHB Program and OPM will not uphold the denial.

2007 Organ/Tissue Transplants and Diagnoses [29 KB]

Download this Letter as a PDF File [130 KB]

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