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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that stem cell transplantation is a process in which stem cells are harvested from either a patient's (autologous) or donor's (allogeneic) bone marrow or peripheral blood for intravenous infusion. Autologous stem cell transplantation (AuSCT) is a technique for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies. You can find this rule in National Coverage Determination (NCD) for Stem Cell Transplantation (Formerly 110.8.1) (110.23) - Effective January 27, 2016. The rules say that effective for services performed on or after April 28, 1989, AuSCT is considered reasonable and necessary under l862(a)(1)(A) of the Act for the following conditions and is covered under Medicare for patients with: 1. Acute leukemia in remission who have a high probability of relapse and who have no human leucocyte antigens (HLA)-matched; 2. Resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response; 3. Recurrent or refractory neuroblastoma; or, 4. Advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched donor. You can find this rule in National Coverage Determination (NCD) for Stem Cell Transplantation (Formerly 110.8.1) (110.23) - Effective January 27, 2016. The rules say that effective October 1, 2000, single AuSCT is only covered for Durie-Salmon Stage II or III patients that fit the following requirements: -Newly diagnosed or responsive multiple myeloma. This includes those patients with previously untreated disease, those with at least a partial response to prior chemotherapy (defined as a 50% decrease either in measurable paraprotein [serum and/or urine] or in bone marrow infiltration, sustained for at least 1 month), and those in responsive relapse; and -Adequate cardiac, renal, pulmonary, and hepatic function. You can find this rule in National Coverage Determination (NCD) for Stem Cell Transplantation (Formerly 110.8.1) (110.23) - Effective January 27, 2016. The rules say that effective for services performed on or after March 15, 2005, when recognized clinical risk factors are employed to select patients for transplantation, high dose melphalan (HDM) together with AuSCT is reasonable and necessary for Medicare beneficiaries of any age group with primary amyloid light chain (AL) amyloidosis who meet the following criteria: -Amyloid deposition in 2 or fewer organs; and, -Cardiac left ventricular ejection fraction (EF) greater than 45%. You can find this rule in National Coverage Determination (NCD) for Stem Cell Transplantation (Formerly 110.8.1) (110.23) - Effective January 27, 2016.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.