Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for transplant-related travel and lodging expenses provided on December 15, 2020.
You asked the Plan to pay for travel and lodging. You say that these expenses used to be covered by the Plan but are not being covered anymore. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this date of service is past the 365-day limit after the transplant took place for travel and lodging reimbursement.
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which a plan provides transplant services at a more distant location, the plan must provide reasonable transportation and accommodations for the enrollee and a companion. Your contract with the Plan says that the Plan will reimburse transportation and lodging costs if you receive transplant services - including follow-up care - at a distant location. We looked at the file and Medicare rules. The Plan denied reimbursement for these travel and lodging costs on the basis that this date of service was more than 365 days after your transplant and therefore is not eligible for reimbursement. The Plan cited 42 Code of Federal Regulations (CFR), Section 488.61(d) to support this; however, this rule only establishes a limit for the amount of time a facility's transplant program may remain inactive before its Medicare participation is revoked and does not establish a limit for the amount of time
following a covered transplant that an enrollee may be eligible for coverage of transplant-related services. The Plan also cited an internal Plan document known as the Transplant Travel Reimbursement Guidelines; however, these guidelines are not in alignment with the benefits described in the Plan's Evidence of Coverage (EOC) for 2020. Furthermore, this guideline was published in 2016 and indicates that it is not a complete description of your benefits and that benefits may change on January 1 of each year. Therefore, the Plan has not shown that any rules or limitations described in the Transplant Travel Reimbursement Guidelines would apply to the services at issue in this case. The Plan has not provided any other rationale to support their denial, nor has the Plan submitted medical records or documented attempts to obtain medical records for the transplant-related follow-up care you were receiving which caused you to incur these travel and lodging expenses. The Plan stated that the transplant procedure you received was covered by the Plan, therefore follow-up care related to this transplant would be included in the Plan's covered benefits. The amount you are requesting payment for is $54.92 for transportation expenses, and your contract with the Plan states that transportation services are not subject to a daily reimbursement limit amount. Based on this information, we decided that Medicare rules and the Plan's rules for coverage of travel and lodging have been met. Therefore, we decided that the Plan has to pay for transplant-related travel and lodging expenses provided on December 15, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.