7.03.05 Small Bowel, Liver and Multivisceral Transplant · A small bowel/liver transplant or a multivisceral transplant includes the small bowel and liver with one or more of the

MEDICAL POLICY – 7.03.05

Small Bowel, Liver and Multivisceral Transplant

BCBSA Ref. Policy: 7.03.05, 7.03.14

Effective Date: Nov. 1, 2019

Last Revised: Oct. 4, 2019

Replaces: 7.03.511

RELATED MEDICAL POLICIES:

7.03.04 Isolated Small Bowel Transplant

Select a hyperlink below to be directed to that section.

POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING

RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Food is digested and nutrients are absorbed in the intestines. If the intestines are damaged

because of surgery, disease, or a birth defect, the ability to absorb nutrients and fluids may be

affected. If part of the intestines is damaged, it may result in a condition called “short bowel

syndrome”. People with short bowel syndrome have a hard time absorbing nutrients and fluids.

As a result, they may become malnourished and need to get their nutrition through “total

parenteral nutrition” (TPN) in order to stay alive. TPN is liquid nutrition that is given through a

vein. Long-term use of TPN can cause complications including liver damage that can lead to

liver failure.

An intestinal transplant is a last-resort treatment for patients with life-threatening complications

from TPN. This policy addresses transplantation of the small bowel, the small bowel/liver

together, and multivisceral transplantation that may include the stomach, duodenum, jejunum,

ileum, pancreas, or colon.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The

rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for

providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can

be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a

service may be covered.

https://www.premera.com/medicalpolicies/7.03.04.pdf

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Policy Coverage Criteria

Transplant Medical Necessity Transplants; multivisceral,

small bowel, liver

Transplants, such as a multivisceral transplant and a small

bowel and liver transplant, may be considered medically

necessary for pediatric and adult patients with all of the

following:

• Patients with intestinal failure

o characterized by loss of absorption and the inability to

maintain protein-energy, fluid, electrolyte, or micronutrient

balance; and

• Patients who have been managed with long-term total

parenteral nutrition; and

• Patients who have developed evidence of impending end-stage

liver failure (eg, total bilirubin > 3 mg/dL)

Retransplants;

multivisceral, small bowel,

liver

Retransplants, such as a multivisceral retransplant and a small

bowel and liver retransplant, may be considered medically

necessary after a failed primary small bowel and liver

transplant or multivisceral transplant.

Transplant Investigational Transplants; small bowel,

liver, or multivisceral

A small bowel and liver transplant, or multivisceral transplant,

is considered investigational in all other situations not outlined

above.

HCV (hepatitis-C) viremic

solid organs

The transplantation of HCV-viremic solid organs (kidney, lung,

heart, liver, small bowel, pancreas) to an HCV non-viremic

recipient combined with direct-acting antiviral treatment for

HCV is considered investigational.

Documentation Requirements The patient’s medical records submitted for review for all conditions should document that

medical necessity criteria are met. The record should include the following:

• Office visit notes that contain the relevant history and physical supporting that patient has

intestinal failure, has been managed with long-term TPN, and has developed evidence of

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Documentation Requirements impending end-stage liver failure. Specify if the request is for small bowel and liver and/or

multivisceral organs or a retransplantation.

Coding

Code Description

CPT 47135 Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any

age

HCPCS

S2053 Transplantation of small intestine, and liver allografts

S2054 Transplantation of multivisceral organs

S2152 Solid organ(s), complete or segmental, single organ or combination of organs;

deceased or living donor (s), procurement, transplantation, and related complications;

including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical,

diagnostic, emergency, and rehabilitative services, and the number of days of pre and

posttransplant care in the global definition

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS

codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Related Information

Intestinal failure results from surgical resection, congenital defect, or disease-associated loss of

absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or

micronutrient balance. Short bowel syndrome is an example of intestinal failure.

Small Bowel/Liver-Specific Criteria

Evidence of intolerance of total parenteral nutrition (TPN) includes, but is not limited to, multiple

and prolonged hospitalizations to treat TPN-related complications or the development of

progressive but reversible liver failure. In the setting of progressive liver failure, small bowel

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transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN

and would thus avoid the necessity of a multivisceral transplant.

Contraindications

Potential contraindications for solid organ transplant are subject to the judgment of the

transplant center include the following:

• Known current malignancy, including metastatic cancer

• Recent malignancy with high risk of recurrence

• History of cancer with a moderate risk of recurrence

• Systemic disease that could be exacerbated by immunosuppression

• Untreated systemic infection making immunosuppression unsafe, including chronic infection

• Other irreversible end-stage disease not attributed to intestinal failure

• Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

Benefit Application

See member’s plan contract language for organ transplant benefits and specific benefits related

to transport, lodging, and donor services. Please note limitations in coverage based on the

transplant benefit, if applicable.

Evidence Review

Description

This policy addresses transplantation and retransplantation of an intestinal allograft in

combination with a liver allograft, either alone or in combination with one or more of the

following organs: stomach, duodenum, jejunum, ileum, pancreas, or colon.

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Background

Short Bowel Syndrome

Short bowel syndrome is defined as an inadequate absorbing surface of the small intestine due

to extensive disease or surgical removal of a large portion of the small intestine. In some

instances, short bowel syndrome is associated with liver failure, often due to the long-term

complications of total parenteral nutrition.

Treatment

A small bowel/liver transplant or a multivisceral transplant includes the small bowel and liver

with one or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas,

and/or colon. The type of transplantation depends on the underlying etiology of intestinal

failure, quality of native organs, presence or severity of liver disease, and history of prior

abdominal surgeries.1 A multivisceral transplant is indicated when anatomic or other medical

problems preclude a small bowel/liver transplant. Complications following small bowel/liver and

multivisceral transplants include acute or chronic rejection, donor-specific antibodies, infection,

lymphoproliferative disorder, graft-versus-host disease, and renal dysfunction.2

Summary of Evidence

For individuals who have intestinal failure and evidence of impending end-stage liver failure who

receive a small bowel and liver transplant alone or multivisceral transplant, the evidence includes

a limited number of case series. The relevant outcomes are overall survival, morbid events, and

treatment-related mortality and morbidity. These transplant procedures are infrequently

performed, and few reported case series exist. However, results from the available case series

have revealed fairly high postprocedural survival rates. Given these results and the exceedingly

poor survival rates of patients who exhaust all other treatments, transplantation may prove not

only to be the last option but also a beneficial one. Transplantation is contraindicated for

patients in whom the procedure is expected to be futile due to comorbid disease, or in whom

posttransplantation care is expected to significantly worsen comorbid conditions. The evidence

is sufficient to determine that the technology results in a meaningful improvement in the net

health outcome.

For individuals who have a failed small bowel and liver or multivisceral transplant without

contraindications for retransplant who receive a small bowel and liver retransplant alone or

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multivisceral retransplant, the evidence includes case series. The relevant outcomes are overall

survival, morbid events, and treatment-related mortality and morbidity. Although limited in

quantity, the available post retransplantation data have suggested reasonably high survival

rates. Given the exceedingly poor survival rates without retransplantation of patients who have

exhausted other treatments, evidence of postoperative survival from uncontrolled studies is

sufficient to demonstrate that retransplantation provides a survival benefit in appropriately

selected patients. Retransplantation is contraindicated for patients in whom the procedure is

expected to be futile due to comorbid disease or in whom posttransplantation care is expected

to significantly worsen comorbid conditions. The evidence is sufficient to determine that the

technology results in a meaningful improvement in the net health outcome.

For individuals who are HCV non-viremic who have end-stage organ disease and are candidates

for a solid organ transplant such as for small bowel or pancreas, evidence for the use of HCV

viremic donor organs as an alternative to continuing appropriate medical treatment and

remaining on the transplant wait-list has not been reported in the last five years in the published

literature. The evidence is insufficient to determine the effects of the technology on health

outcomes.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in June 2019 did not identify any ongoing or unpublished trials

that would likely influence this review.

Practice Guidelines and Position Statements

American Gastroenterological Association

The American Gastroenterological Association (2003) published a position statement on short

bowel syndrome and intestinal transplantation.23 The statement noted that only patients with

life-threatening complications due to intestinal failure or long-term total parenteral nutrition

have undergone intestinal transplantation. The statement recommended the following

Medicare-approved indications, pending availability of additional data:

• Impending liver failure

• Thrombosis of major central venous channels

• Frequent central line-associated sepsis

http://www.clinicaltrials.gov/

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• Frequent severe dehydration.

American Society of Transplantation

The American Society of Transplantation (2001) issued a position paper on indications for

pediatric intestinal transplantation.24 The Society listed the following disorders in children as

being potentially treatable by intestinal transplantation: short bowel syndrome, defective

intestinal motility, and impaired enterocyte absorptive capacity. Contraindications for intestinal

transplant to treat pediatric patients with intestinal failure are similar to those of other solid

organ transplants: profound neurologic disabilities, life-threatening comorbidities, severe

immunologic deficiencies, nonresectable malignancies, autoimmune diseases, and insufficient

vascular patency.

The American Society of Transplantation (2017) convened a consensus conference of experts to

address issues related to the transplantation of hepatitis C virus (HCV) viremic solid organs into

HCV non-viremic recipients and concluded that the transplantation of organs from HCV viremic

donors into HCV-negative recipients should be conducted only under monitored IRB-approved

protocols and studies.

Medicare National Coverage

Medicare covers intestinal transplantation for the purposes of restoring intestinal function in

patients with irreversible intestinal failure only when performed for patients who have failed

total parenteral nutrition and only when performed in centers that meet approved criteria.25 The

criteria for approval of centers are based on a "volume of 10 intestinal transplants per year with

a 1-year actuarial survival rate of 65 percent using the Kaplan-Meier technique."

Regulatory Status

Small bowel/liver and multivisceral transplantation are surgical procedures and, as such, are not

subject to regulation by the U.S. Food and Drug Administration.

The U.S. Food and Drug Administration regulates human cells and tissues intended for

implantation, transplantation, or infusion through the Center for Biologics Evaluation and

Research, under Code of Federal Regulation Title 21, parts 1270 and 1271. Pancreas transplants

are included in these regulations.

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References

1. Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf).

Feb 2017;5(1):20-28. PMID 28130374.

2. Loo L, Vrakas G, Reddy S, et al. Intestinal transplantation: a review. Curr Opin Gastroenterol. May 2017;33(3):203-211. PMID

28282321.

3. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Small bowel transplants in adults and multivisceral

transplants in adults and children. TEC Assessments. 1999;Volume 14:Tab 9.

4. Mangus RS, Tector AJ, Kubal CA, et al. Multivisceral transplantation: expanding indications and improving outcomes. J

Gastrointest Surg. Jan 2013;17(1):179-186; discussion p 186-177. PMID 23070622.

5. Abu-Elmagd KM, Costa G, Bond GJ, et al. Five hundred intestinal and multivisceral transplantations at a single center: major

advances with new challenges. Ann Surg. Oct 2009;250(4):567-581. PMID 19730240.

6. Desai CS, Khan KM, Gruessner AC, et al. Intestinal retransplantation: analysis of Organ Procurement and Transplantation

Network database. Transplantation. Jan 15 2012;93(1):120-125. PMID 22113492.

7. Lacaille F, Irtan S, Dupic L, et al. Twenty-eight years of intestinal transplantation in Paris: experience of the oldest European

center. Transpl Int. Feb 2017;30(2):178-186. PMID 27889929.

8. Garcia Aroz S, Tzvetanov I, Hetterman EA, et al. Long-term outcomes of living-related small intestinal transplantation in

children: A single-center experience. Pediatr Transplant. Jun 2017;21(4). PMID 28295952.

9. Dore M, Junco PT, Andres AM, et al. Surgical rehabilitation techniques in children with poor prognosis short bowel syndrome.

Eur J Pediatr Surg. Feb 2016;26(1):112-116. PMID 26535775.

10. Rutter CS, Amin I, Russell NK, et al. Adult intestinal and multivisceral transplantation: experience from a single center in the

United Kingdom. Transplant Proc. Mar 2016;48(2):468-472. PMID 27109980.

11. Lauro A, Zanfi C, Dazzi A, et al. Disease-related intestinal transplant in adults: results from a single center. Transplant Proc. Jan-

Feb 2014;46(1):245-248. PMID 24507060.

12. Varkey J, Simren M, Bosaeus I, et al. Survival of patients evaluated for intestinal and multivisceral transplantation - the

Scandinavian experience. Scand J Gastroenterol. Jun 2013;48(6):702-711. PMID 23544434.

13. Nagai S, Mangus RS, Anderson E, et al. Cytomegalovirus infection after intestinal/multivisceral transplantation: a single-center

experience with 210 cases. Transplantation. Feb 2016;100(2):451-460. PMID 26247555.

14. Timpone JG, Yimen M, Cox S, et al. Resistant cytomegalovirus in intestinal and multivisceral transplant recipients. Transpl Infect

Dis. Apr 2016;18(2):202-209. PMID 26853894.

15. Wu GS, Cruz RJ, Jr., Cai JC. Acute antibody-mediated rejection after intestinal transplantation. World J Transplant. Dec 24

2016;6(4):719-728. PMID 28058223.

16. Cromvik J, Varkey J, Herlenius G, et al. Graft-versus-host disease after intestinal or multivisceral transplantation: a Scandinavian

single-center experience. Transplant Proc. Jan-Feb 2016;48(1):185-190. PMID 26915866.

17. Florescu DF, Qiu F, Langnas AN, et al. Bloodstream infections during the first year after pediatric small bowel transplantation.

Pediatr Infect Dis J. Mar 29 2012;31(7):700-704. PMID 22466325.

18. Wu G, Selvaggi G, Nishida S, et al. Graft-versus-host disease after intestinal and multivisceral transplantation. Transplantation.

Jan 27 2011;91(2):219-224. PMID 21076376.

Page | 9 of 10 ∞

19. Organ Procurement and Transplantation Network (OPTN). Organ Procurement and Transplantation Network Policies. 2018;

https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf Accessed October 2019.

20. Working Party of the British Transplantation Society. Kidney and Pancreas Transplantation in Patients with HIV. Second Edition

(Revised). British Transplantation Society Guidelines. Macclesfield, UK: British Transplantation Society; 2017.

21. Ekser B, Kubal CA, Fridell JA, et al. Comparable outcomes in intestinal retransplantation: Single-center cohort study. Clin

Transplant. May 21 2018:e13290. PMID 29782661.

22. Mazariegos GV, Soltys K, Bond G, et al. Pediatric intestinal retransplantation: techniques, management, and outcomes.

Transplantation. Dec 27 2008;86(12):1777-1782. PMID 19104421.

23. American Gastroenterological Association (AGA). American Gastroenterological Association medical position statement: short

bowel syndrome and intestinal transplantation. Gastroenterology. Apr 2003;124(4):1105-1110. PMID 12671903.

24. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American

Society of Transplantation. Pediatr Transplant. Apr 2001;5(2):80-87. PMID 11328544.

25. Center for Medicare & Medicaid Services. National Coverage Determination (NCD) for Intestinal and Multi- Visceral

Transplantation (260.5). 2006; https://www.cms.gov/medicare-coverage-database/details/ncd-

details.aspx?NCDId=280&ncdver=2&CoverageSelection=National&KeyWord=intestinal&KeyWordLookUp=Title&Key

WordSearchType=And&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+m

ay+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&b

c=gAAAACAAAAAAAA%3d%3d& Accessed October 2019.

26. Levitsky J, Formica RN, Bloom RD, et al. The American Society of Transplantation Consensus Conference on the Use of Hepatitis

C Viremic Donors in Solid Organ Transplantation. Am J Transplant. Nov 2017;17(11):2790-2802. PMID 28556422.

History

Date Comments 11/01/19 New policy, approved October 4, 2019. This policy replaces policy 7.03.511 which is

now deleted. Policy created with literature review through June 2019. Multivisceral,

small bowel, and liver transplants may be considered medically necessary when criteria

are met, considered investigational in all other situations not outlined in the medical

necessity criteria. Policy statement on transplantation of HCV viremic organs is taken

from BCBSA policy 7.03.14.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The

Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and

local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review

and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit

booklet or contact a member service representative to determine coverage for a specific medical service or supply.

CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2019 Premera

All Rights Reserved.

https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdfhttps://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=280&ncdver=2&CoverageSelection=National&KeyWord=intestinal&KeyWordLookUp=Title&KeyWordSearchType=And&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&bc=gAAAACAAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=280&ncdver=2&CoverageSelection=National&KeyWord=intestinal&KeyWordLookUp=Title&KeyWordSearchType=And&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&bc=gAAAACAAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=280&ncdver=2&CoverageSelection=National&KeyWord=intestinal&KeyWordLookUp=Title&KeyWordSearchType=And&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&bc=gAAAACAAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=280&ncdver=2&CoverageSelection=National&KeyWord=intestinal&KeyWordLookUp=Title&KeyWordSearchType=And&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&bc=gAAAACAAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=280&ncdver=2&CoverageSelection=National&KeyWord=intestinal&KeyWordLookUp=Title&KeyWordSearchType=And&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&bc=gAAAACAAAAAAAA%3d%3d&

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Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when

determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to

the limits and conditions of the member benefit plan. Members and their providers should consult the member

benefit booklet or contact a customer service representative to determine whether there are any benefit limitations

applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

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Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357).

Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357).

Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).

Italiano ( ):Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).

Italian

中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期

之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母

語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。

037338 (07-2016)

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:[email protected]

日本語 (Japanese):この通知には重要な情報が含まれています。この通知には、 Premera Blue Crossの申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要な日付をご確認くだ

さい。健康保険や有料サポートを維持するには、特定の期日までに行動を

取らなければならない場合があります。ご希望の言語による情報とサポー

トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話ください。

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນີ້. ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົດ ເວລາສະເພາະເພື່ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລື່ອງ າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນີ້ ແລະ ຄວາມຊ່ວຍເຫຼື ອເປັ ນພາສາ ຂອງທ່ານໂດຍບ່ໍ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357).

ູຂໍ້

່

ສໍ ັ

ຈ

ໝ

ສິ

ັ

່

ວ

ຄ

ມ

ມູຮັ

ູມີ ມຂໍ້

ភាសាែខមរ ( ): ឹ

រងរបស់

Premera Blue Cross ។ របែហលជាមាន កាលបរ ិ ឆ ំខានេនៅកងេសចក

េសចកតជី ូ

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់

នដំ ងេនះមានព័ ី

តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ណ ត៌មានយ៉ា ំ ់ តងសខាន។ េសចក

េចទស ់ ន ុ ត

ណងេនះ។ អ វការបេញញសមតភាព ដលកណតៃថ ចបាស

កតាមរយៈ

ដំ ឹ នករបែហលជារតូ ច ថ ់ ំ ់ ងជាក់ ់

នដ

ន

ី ន

ូ

អ

ូ

ជ

ជ

ំណឹងេនះរបែហល

នានា េដើ ីនងរកសាទុ ៉ បរងស់ ុ ់ ក ឬរបាក់ ំ

អ

មប ឹ កការធានារា ខភាពរបស ជ

ធនកមានសិ ទទលព័ មានេនះ និ ំ យេនៅកុងភាសារបសទិ ួ ត៌ ងជ ននួ

ន

់ កេដាយម

អ

នអ

យេចញៃថល។ ួ

នអស

ន

ិ

លុ ើ ូ ូយេឡយ។ សមទ ទ រស័ព 800-722-1471 (TTY: 800-842-5357)។

Khmer

ਕਵਰਜ ਅਤ ਅਰਜੀ ਬਾਰ ਮਹ ਤਵਪਰਨ ਜਾਣਕਾਰੀ ਹ ਸਕਦੀ ਹ . ਇਸ ਨ ਿਜਸ ਜਵਚ ਖਾਸ

ਤਾਰੀਖਾ ਹ ਸਕਦੀਆ ਹਨ. ਜੇਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵਚ ਮਦਦ ਦ ੇਇਛ ੁਕ ਹ ਤਾਂ ਤਹਾਨ ਅ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ ਝ ਖਾਸ ਕਦਮ ਚ ਕਣ ਦੀ ਲੜ ਹ ਸਕਦੀ ਹ ,ਤਹੁਾਨ ਮਫ਼ਤ ਿਵਚ ਤ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਚ ਜਾਣਕਾਰੀ ਅਤ ਮਦਦ ਪਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-722-1471 (TTY: 800-842-5357).

ਪ ਜਾਬੀ (Punjabi): ਇਸ ਨ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ. ਇਸ ਨ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ

ੰ

ੰ

ੇ ੇ ੇ ੱ ੂ ੋ ੈ ੋੋ ਂ ੁ ੇ ੱ ੋ ੇ ੱੱ ੁ ੱ ੂੁ ੱ ੇ ੱ ੇ ੍ਰ ੈ

ੋ ੰ ੂ ੱ ੁ ੋ ੋ ੈ ੰ

ੋ ੈ ੋ

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين. ميباشد ھمم اطالعات یوحا يهمالعا اين

در ھمم ھای خيتار به باشد.پ رایبستاکنممماش زينهھ اختدپر در مککيا تان بيمهوشش حقظ

Premera Blue Cross طريق از ماش مهبيوشش يا و تقاضا ای پ. يدماين جهتو يهمالعا اين

حق شما. يدشاب داشته اجتياح صیاخ کارھای امانج برای صیمشخ ایھ خيتار به تان، انیمدر ھای کسب برای .نماييد دريافت گانيرا ورط به ودخ زبان به را کمک و اطالعات اين که داريد را اين

استم ) 5357-842-800 مارهباش ماست TTY انکاربر(800-722-1471 مارهش با اطالعات .اييدنم برقرار

้

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może

zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-722-1471 (TTY: 800-842-5357).

Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter e sta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 (TTY: 800-842-5357).

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357).

Español ( ): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este

tiene derecho a recibir esta información y ayuda en su idioma sin costo

aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted

alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

Spanish

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).

ไทย (Thai): ประกาศนมขอมลสาคญ ประกาศนอาจมขอมลทสาคญเกยวกบการการสมครหรอขอบเขตประกน สขภาพของคณผาน Premera Blue Cross และอาจมกาหนดการในประกาศน คณอาจจะตอง ดาเนนการภายในกาหนดระยะเวลาทแนนอนเพอจะรกษาการประกนสขภาพของคณหรอการชวยเหลอท มคาใชจาย คณมสทธทจะไดรบขอมลและความชวยเหลอนในภาษาของคณโดยไม่มคาใชจาย โทร 800-722-1471 (TTY: 800-842-5357)

้ี ี ้ ู ํ ั ้ี ี ้ ู ่ี ํ ั ่ี ั ั ื ัุ ุ ่ ี ํ ี ุ ้ํ ิ ํ ่ี ่ ่ื ั ั ุ ุ ื ่ ื ่ีี ่ ้ ่ ุ ี ิ ิ ่ี ้ ั ้ ู ่ ื ้ี ุ ี ่ ้ ่

Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-722-1471 (TTY: 800-842-5357).

Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).