|
36.4.30.6 Lung 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, lung transplants (single lung with bronchial anastomosis or double sequential lung with bilateral bronchial anastomosis) have been determined to be a benefit of the Texas Medicaid Program. A lung transplant for individual Medicaid clients is subject to prior authorization and must be performed in an institution approved as a lung transplant facility by the Texas Medicaid Program.
A lung transplant to a client must be documented as unresponsive to more conventional and/or standard therapies to be considered for coverage.
Prior authorization is required for a heart/lung transplant and must follow criteria for both heart and lung transplants. Requests for a heart/lung transplant are considered on an individual basis.
Guidelines for Coverage of a Lung Transplant
Lung transplant candidates must be limited to those patients who, based on sound patient selection criteria, would most likely benefit from the lung (single or double) 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.
•Symptoms at rest directly related to chronic pulmonary disease and resultant severe functional limitation.
•Lung transplantation may be authorized with documentation of end-stage pulmonary diseases in these categories:
•Obstructive lung disease.
•Restrictive lung disease.
•Cystic Fibrosis.
•Pulmonary hypertension.
•An absence of comorbidities such as:
•End-stage renal, hepatic, or other organ dysfunction 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.
Organ Procurement
The appropriate DRG reimbursement coverage to the approved institution for a prior authorized transplant procedure includes procurement of the organ and services associated with the organ procurement as specified by HHSC or its designee. Documentation of organ procurement must be maintained in the hospital medical records. Organ procurement costs are not payable to a physician.
Physician services for the procurement of peripheral stem cells are not reimbursable.
|
