Issued and entered December 27, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 22, 2002 the Petitioner, XXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (“Commissioner”) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. The Commissioner accepted the request on October 29, 2002.

The issue involved in the adverse determination is contractual. The Commissioner reviews contractual issues pursuant to MCL 550.1911(7). Review by an independent review organization is not required. The Commissioner notified Blue Cross and Blue Shield of Michigan (“BCBSM”) of the Petitioner’s filing and requested the information it used in making its adverse determination. The Office of Financial and Insurance Services received the BCBSM information on November 7, 2002.

II
FACTUAL BACKGROUND

The Petitioner is disputing BCBSM’s failure to preauthorize a simultaneous pancreas-kidney transplant for him at the XXXXXXXXXXXX, XXXXXXXXXXXXXXXXXXXXXX, or the XXXXXXXXXX XXXXXXXXXXXXXXXX. BCBSM failed to approve this procedure because these hospitals are not BCBSM-designated facilities for this type of transplant.

Petitioner argues that there is no designated facility for simultaneous pancreas-kidney transplant in Michigan. He believes that BCBSM should approve this care since the XXXXXXXXX XXXXXX, XXXXXXXXXXXXXXXXXXXX and XXXXXXXXXXXXXXXXXXX all have excellent reputations for this procedure.

III
ISSUE

Is BCBSM required to pay for a simultaneous pancreas-kidney transplant for the Petitioner at one of the facilities chosen by Petitioner?

IV
ANALYSIS

Petitioner’s Argument

The Petitioner is a severe diabetic on an insulin pump. He was diagnosed with lymphoma, underwent chemotherapy, and subsequently lost a transplanted kidney he had had for twelve years. Petitioner has consulted with the XXXXXXXXXXXXXXX and XXXXXXXXXXXXXXX and has been in touch with the XXXXXXXXXXXXXXXXXXX. The doctors at those facilities have recommended a simultaneous pancreas-kidney transplant. This would eliminate his diabetes and would give the kidney a much better chance of long-term success.

Petitioner says he has never been given a reason why none of the three hospitals that he has consulted are not on BCBSM’s designated list for pancreas-kidney transplants. It does not make sense to him that these facilities would be approved for kidney but not pancreas-kidney transplants since all three facilities have excellent reputations and are highly recommended.

Respondent’s Argument

Petitioner has coverage through XXXXXXXXXXXXXXXXXXXXXXX. The Community Blue Group Benefit Certificate governs that coverage. Rider SOT-PE (Specified Organ Transplants In Designated Facilities) also applies.

Under the rider, inpatient hospital care services are a covered benefit for specific organ transplants. Simultaneous pancreas-kidney transplant is included under the rider. The rider covers the cost of travel and lodging to the transplant facility for both the patient and another person eligible to accompany the patient. The rider does not pay for transplants that are not pre-approved or that are not performed in a BCBSM-designated facility.

BCBSM says that it has informed Petitioner that the XXXXXXXXXXXXXX, the XXXXXXXXXXX, and the XXXXXXXXXXXXXXXXXXX are not BCBSM-designated facilities for simultaneous pancreas-kidney transplants. BCBSM-designated facilities are qualified for the designation by the national Blue Cross and Blue Shield Association through its transplant network, the Blue Quality Centers for Transplant. The transplant network establishes selection criteria for each type of transplant. It also monitors morbidity and survival rates to measure continued performance of the participating institutions and staff. Finally, it establishes global network pricing which makes transplant costs more predictable for Blue Cross and Blue Shield plans.

BCBSM points out that there are three designated facilities for simultaneous pancreas-kidney transplants in the area. They are XXXXXXXXXXXXXXXXXXXX and the XXXXXXXXXXX XXXXXXXXXXXX in XXXXXXX and XXXXXXXXXXXXXXXXXX in XXXXX. These facilities are about the same distance from the Petitioner’s home as the XXXXXXXXXXXX and the XXXXXXXXXXXXXXXX.
BCBSM also states that the waiting lists for the three designated facilities are no longer than the lists for the hospitals requested by Petitioner. Therefore, BCBSM believes that the Petitioner would not be disadvantaged by using a designated facility.

BCBSM believes that it acted properly when it denied pre-approval for the Petitioner’s transplant at a non-approved hospital.

Commissioner’s Review

The Certificate of coverage controls the analysis of this matter. Rider SOT-PE states in part:

When performed in a BCBSM–designated facility, we pay for transplantation of the following organs:

• Simultaneous pancreas–kidney
  

BCBSM established that the XXXXXXXXXXXXXX, the XXXXXXXXXXXXXXXXX, and the XXXXXXXXXXXXX are not BCBSM-designated hospitals for simultaneous pancreas-kidney transplants. BCBSM also established that XXXXXXXXXXXXXXXXXXXXXXXXXXXX, XXXXXXXXXX XXXXXXXXXXXXXXXX, and XXXXXX are designated facilities that could perform Petitioner’s transplant.

V
ORDER

The final adverse determination of BCBSM dated August 12, 2002, is upheld. BCBSM is not required to pre-approve or pay for a simultaneous pancreas-kidney transplant at the XXXXXXXXX XXXXXX, XXXXXXXXXXXXXXXX, or XXXXXXXXXXXXXXXXXXXXXX.

This is a final decision of an administrative agency. Under MCL 550.1915, MCL 600.631, MCR 7.101 and MCR 7.104, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.