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36.4.30.5 Liver Transplants
Under current Texas Medicaid Program policy, procedures are considered to be medically necessary and reasonable, based on safety and efficacy, demonstrated by scientific evidence and by controlled clinical studies.
Based on published research and clinical studies, liver transplants have been determined to be a benefit of the Texas Medicaid Program for Medicaid-eligible clients. A liver transplant for individual Medicaid clients is subject to prior authorization and must be performed in an institution approved as a liver transplant facility by the Texas Medicaid Program.
Guidelines for Coverage
Authorization of liver transplantation requires documentation of life threatening complications of acute liver failure or chronic end-stage liver disease.
Liver transplant candidates must be limited to those patients who, based on sound patient selection criteria, would most likely benefit from the liver transplant procedure on a long-term basis. To be reimbursed by the Texas Medicaid Program, the facility must document the following considerations:
• A critical medical need with a likelihood of a successful clinical outcome.
•Liver disease in one of the following categories:
•Primary cholestatic liver disease.
•Other cirrhosis:
•Alcoholic.
•Hepatitis C, non-A, non-B, and Hepatitis B.
•Fulminant hepatic failure.
•Metabolic diseases.
•Malignant neoplasms.
•Benign neoplasms.
•Biliary atresia.
•An absence of comorbidities such as:
•End-stage cardiac, pulmonary, or renal disease unrelated to primary disorder.
•Multiple organ compromise secondary to infection, malignancy, or condition with no known cure.
Documented compliance with other medical treatments, regimen, and plan of care.
Documented compliance includes no active alcohol or chemical dependency that interferes with compliance to a medical regimen.
Documented psychiatric instability is a contraindication for transplant if severe enough to jeopardize incentive for adherence to medical regimen.
Payment for liver transplant professional services is made under procedure code 2/8-47135 or 2/8-47136. These procedures include six months of professional postoperative care. Separate charges for procedure code 2/8-47780 are denied as part of the liver transplant. Parenteral immunosuppressant therapy is approved for a period of 12 months following the date of discharge from the hospital, conditional upon the client's Medicaid eligibility.
Services unrelated to the liver transplant surgery are paid separately.
Two assistant surgeons are allowed for liver transplant surgery using procedure codes 8-47135 or 8-47136.
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