25.2.3.5 Organ/Tissue Transplant ServicesPrior Authorization Prior authorization for a transplant is mandatory and approved only if the physician indicates the transplant will be performed in an approved Texas Medicaid transplant facility. If the facility indicated on the original authorization request is not a Medicaid-approved transplant facility, the physician needs to designate a different approved facility before the authorization is given. Transplant facilities are reviewed for approval each year. TMHP issues prior authorizations for dates within the facility approval period. Note: If the client is a Medicaid Managed Care client, all prior authorizations for transplants will need to be obtained from the client's health plan. If the transplant has not been performed by the end of the authorization period, physicians need to apply for an extension. Fax inquiries for authorization extensions to TMHP Special Medical Prior Authorization at 1-512-514-4213. Prior authorization is required for the following services (this noninclusive list is subject to change):
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• The prior authorization number (PAN) must be entered in Block 63 (Treatment Authorization Code) of the UB-04 CMS-1450 claim form. Cornea transplants do not require prior authorization. Documentation supplied with the prior authorization request should include a complete history and physical, a statement of the client's current medical problems and status, and meet the criteria specified in the individual transplant policy for which the facility is requesting prior authorization. If a solid organ transplant is not prior authorized, services directly related to the transplant within the three day preoperative and six weeks postoperative period also will be denied, regardless of who provides the service, (i.e., laboratory services, status-post visits, and radiology services). Services unrelated to the transplant surgery will be paid separately. A transplant request signed by a physician associated with one of the Texas Medicaid Program approved transplant facilities is considered for prior authorization after the client has been evaluated and meets the guidelines of the institution's transplant protocol. All supporting documentation must be included with the request for authorization. Send requests and documentation to the following address:
Texas Medicaid & Healthcare Partnership Heart Transplants Heart transplant candidates must be limited to those clients who, based on sound patient selection criteria, would most likely benefit from the heart transplant procedure on a long-term basis. In order to be reimbursed by the Texas Medicaid Program, the facility must document a critical medical need with the New York Heart Association (NYHA) Class III or IV cardiac disease as shown below:
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• Documented psychiatric instability is a contraindication for transplant if severe enough to jeopardize incentive for adherence to medical regimen. Prior authorization for a heart/lung transplant must follow criteria for both heart and lung transplants. Requests for a heart/lung transplant will be considered on an individual basis. All heart transplant services provided by facilities and professionals must be prior authorized by HHSC or its designee. Documentation supplied with the prior authorization request must address the criteria above and must be medically necessary, reasonable, and federally-allowable. Liver Transplants 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 clients who, based on sound patient selection criteria, would most likely benefit from the liver transplant procedure on a long-term basis. In order to be reimbursed by the Texas Medicaid Program, the facility must document the following:
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• Documented psychiatric instability is a contraindication for transplant if it is severe enough to jeopardize incentive for adherence to medical regimen. Payment for liver transplant professional services will be made under procedure code 2/8-47135 or 2/8-47136. These procedures include six months of professional postoperative care. Separate charges for a choledochojejunostomy (Roux-en-y) should be 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 Medicaid-eligibility of the client. Two assistant surgeons will be allowed for liver transplant surgery using procedure codes 8-47135 and 8-47136. Lung Transplants Lung transplant candidates must be limited to those clients who, based on sound patient selection criteria, would most likely benefit from the lung (single or double) transplant procedure on a long-term basis. In order to be reimbursed by the Texas Medicaid Program, the facility must document the following:
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• Documented psychiatric instability is a contraindication for transplant if it is severe enough to jeopardize incentive for adherence to medical regimen. Prior authorization for a heart/lung transplant must follow criteria for both heart and lung transplants. Requests for a heart/lung transplant will be considered on an individual basis. Pancreas Transplant/Simultaneous Kidney-Pancreas Transplant Based upon published research and clinical studies, pancreas transplants and simultaneous kidney-pancreas transplants have been determined to be a benefit of the Texas Medicaid Program. A pancreas transplant or simultaneous kidney-pancreas transplant for individual Medicaid clients is subject to prior authorization and must be performed in an institution approved as a kidney and pancreas transplant facility by the Texas Medicaid Program. For benefit consideration under this policy for a pancreas transplant and simultaneous kidney-pancreas transplant, there must be documentation that aggressive conventional and/or standard therapies have failed. Texas Medicaid Program approval is limited to facilities that are certified by United Network of Organ Sharing (UNOS) and have written documentation of agreement from the facility ethics and transplant committees in support of the specific transplant. Pancreas Transplant Alone For the pancreas alone transplant, Group 1 or Group 2 documentation is required: Group 1
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• Simultaneous Kidney and Pancreas Transplant For the simultaneous kidney-pancreas transplant, Group 1 or Group 2 documentation is required: Group 1
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• The following contraindictions for transplant applies to both the pancreas and simultaneous kidney-pancreas transplant and are as follows:
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• If a pancreas transplant or simultaneous kidney-pancreas transplant has been prior authorized as medically necessary by the Commission or its designee because of an emergent, life-threatening situation, a maximum of 30 days of inpatient hospital services during a Title XIX spell of illness may be a benefit beginning with the actual first day of the transplant. This coverage is in addition to covered inpatient hospital days provided before the actual first day of the transplant. This 30 day period is considered a separate inpatient hospital admission for reimbursement purposes, but is included under one hospital stay. Program Limitations If a transplant has been prior authorized as medically necessary by HHSC or its designee because of an emergent, life-threatening situation, a maximum of 30 days of inpatient hospital services during Title XIX spell of illness may be a benefit, beginning with the actual first day of the transplant. This benefit is in addition to covered inpatient hospital days provided before the actual first day of the transplant. This 30-day period is considered a separate inpatient hospital admission for reimbursement purposes, but is included under one hospital stay. Physician services that HHSC or its designee determines to be reasonable and medically necessary are also a benefit during the 30-day period. Day limitations do not apply for clients younger than 21 years of age. Expenses for a single inpatient hospital admission for an authorized transplant are not included in the annual $200,000.00 inpatient expenditure cap. Dollar limitations do not apply for clients younger than 21 years of age. All program coverage limits are applied. The above guidelines also apply to one subsequent re-transplant, because of rejection, as a lifetime benefit. A subsequent transplant is not included in the prior authorization for the initial transplant; it must be prior authorized separately. Reimbursement for transplant is limited to an initial transplant as a lifetime benefit and one subsequent re-transplant because of rejection. Expenses incurred by a living donor will not be reimbursed. Transplants are also a benefit under the Medicare program; therefore, for clients eligible for Medicare and Medicaid, the Texas Medicaid Program will pay only the deductible or coinsurance portion as applicable. Prior authorization must be obtained for Medicaid-only clients; authorization will not be given for Medicare/Medicaid-eligible clients. The Texas Medicaid Program will not pay a transplant service denied by Medicare for a Medicare-eligible client. If a Medicaid client receives a transplant in a facility that is not approved by the Texas Medicaid Program, the client must be discharged from the facility to be considered to receive other medical and hospital benefits under the Texas Medicaid Program. Coverage for other services needed as a result of complications of the transplant may be considered when medically necessary, reasonable, and federally allowable. The Texas Medicaid Program will not pay for routine post-transplant services for transplant patients in facilities that are not approved by the Texas Medicaid Program. Services unrelated to the transplant surgery will be paid separately. Benefits are not available for any experimental or investigational services (including xenotransplantation and artificial/bioartificial liver transplants), supplies, or procedures. The DRG payment for the transplant includes procurement of the organ and services associated with the organ procurement. The Texas Medicaid Program does not pay for solid organs procured by a facility for supply to an organ procurement organization (OPO). The Omnibus Budget Reconciliation Act of 1986 (OBRA 86) Public Law 99-509 added Section 1138 of the Social Security Act, which defines conditions of participation for institutions in the organ procurement program. Organ procurement costs are not reimbursed to a hospital that fails to meet the conditions of participation. The specific guidelines may be found in the appropriate areas of 42 CFR Parts 405, 413, 441, 482, and 485. Documentation of organ procurement must be maintained in the hospital's medical record. Expenses incurred by a living donor for transplants will not be reimbursed separately. Refer to: "Reimbursement" . |
Stem cell transplant.
