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6.3.42.5.2 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 Texas Medicaid, 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.
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