DCS Comprehensive Health Plan

Transplant Services

Statement/Purpose

This policy outlines the requirements and criteria for determining medical necessity and appropriate care for transplant services covered by Department of Child Safety Comprehensive Health Plan (DCS CHP).

Definitions

Absolute Contraindication: A condition or circumstance that if present precludes authorization of a transplant regardless of any other considerations.

Hematopoietic Stem Cell Transplants (HSCT): The transplantation of blood stem cells derived from the bone marrow or peripheral blood, including cord blood. Conditioning therapy includes either myeloablative or non-myeloablative induction with or without Total Body Irradiation (TBI).

Medically Necessary: Covered services provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability or other adverse health conditions, or their progression, or prolong life. (A.A.C. R9-22-101, R9-28-101).

Organ Procurement and Transplantation Network (OPTN): Established through the National Organ Transplant Act (NOTA), OPTN is a public-private partnership operated through U.S. Department of Health and Human Services. The OPTN policies govern operation of all member transplant hospitals, Organ Procurement Organizations (OPOs) and histocompatibility labs in the United States.

Standard of Care: A medical procedure or process that is accepted as treatment for a specific illness, injury or medical condition through custom, peer review or consensus by the professional medical community.

Policy

DCS CHP covers transplant services and related immunosuppressant medications which are medically necessary, cost effective, federally and State reimbursable, non-experimental and fall within the medical standard of care. Transplant services which are experimental or which are recommended primarily for the purpose of research are not covered.

DCS CHP through the Early and Periodic Screening Diagnostic and Treatment (EPSDT) Program for individuals under age 21 covers all non-experimental transplants necessary to correct or ameliorate defects, illnesses and physical conditions whether or not the transplant is covered by the AHCCCS State Plan.

DCS CHP and its contracted Managed Care Organization (MCO), consult with current authoritative medical sources to determine whether a request for transplant services is medically necessary, cost-effective, non-experimental, and not primarily for purposes of research. DCS CHP may also consult with the transplantation management entity under contract with AHCCCS.

DCS CHP applies eligibility criteria and processes outlined in AHCCCS Medical Policy Manual (AMPM), Policy 310-DD, in making authorization and coverage determinations for transplant services.

Procedure

Overview

All transplants require prior authorization. DCS CHP and its contracted MCO, Mercy Care, are responsible for care coordination, and reimbursement for all components covered under the transplant contract.

Consideration for coverage of transplants begins with a Request for Transplant Evaluation by the member’s Primary Care Provider (PCP) and/or specialist(s) treating the condition necessitating the transplant who may consider the following criteria to determine whether a referral to a transplant facility for comprehensive evaluation and possible treatment is appropriate for the member:

• The member is able to attain an increased quality of life and chance for long-term survival as a result of the transplant;

• There are no significant impairments or conditions that would negatively impact the transplant surgery, supportive medical services, or inpatient and outpatient post-transplantation management of the member;

• There are strong clinical indications that the member can survive the transplantation procedure and related medical therapy (e.g. chemotherapy, immunosuppressive therapy);

• The psychosocial environment is assessed and appropriate plans generated (including behavioral health services) to address sufficient social support to ensure member compliance with treatment recommendations such as, but not limited to, immunosuppressive therapy, other medication regimens, and pre- and post-transplantation physician visits;

• There is adequate evidence that the pediatric/adolescent member and the parent/guardian/caregiver will adhere to the rigorous therapy, daily monitoring, and re-evaluation schedule after transplant;

• The member has been adequately assessed for potential co-morbid conditions that may impact the success of the transplant and, when the member’s medical condition is such that the evaluation must proceed immediately, the screenings may be conducted concurrent with the transplant evaluation;

• There is continued assessment of the member for changes in medical conditions and their impact on transplant candidacy.

  • With appropriate age/condition screening for disease.

• Any identified infections have a plan of containment in accord with an infectious disease specialist.

• Members with neoplasms are assessed by an oncologist.

• The member’s condition has failed to improve with other conventional medical/surgical therapies and the likelihood of survival with transplantation, considering the member’s diagnosis, age, and comorbidities, is greater than the expected survival rate with conventional therapies.

• The presence of an absolute contraindication precludes authorization for a transplant; and

• For members with substance use disorder, plans for treatment before and after organ transplantation shall be required with the appropriate Behavioral Health Professional.

Organ Procurement and Transplantation Network (OPTN) policies set the criteria for wait listing for organ transplantation.

Consideration for coverage of transplants is documented and submitted to the contracted MCO at the time of the request for evaluation.

A Request for Transplant Evaluation and authorization is not needed if the member is evaluated for transplant while hospitalized. The evaluation is included in the DRG payment.

Coverage

Under the Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Program for members under age 21, all non-experimental transplants are covered as long as they are medically necessary to correct or ameliorate defects, illnesses, and physical conditions, whether or not the particular non-experimental transplant is covered by the AHCCCS State Plan.

Transplant services are covered only when performed in specific settings:

• Solid Organ transplants are performed in a Center for Medicare & Medicaid Services (CMS) certified and United Network of Organ Sharing (UNOS) approved transplant center which meets Medicare criteria for participation and special requirement for transplant centers as delineated by 42 CFR Part 482.

• Hematopoietic stem cell transplant services are provided in a facility that has achieved Foundation for the Accreditation of Cellular Therapy (FACT) accreditation. The facility must also satisfy the Medicare conditions of participation and any additional federal requirements for transplant facilities.

Covered transplant services include (as dictated by the type of transplant):

For the transplant candidate:

• Pre-transplant evaluation (inpatient or outpatient) which includes:

  • Physical examination;

  • Psychosocial evaluation;

  • Laboratory studies;

  • X-ray and diagnostic imaging;

  • Biopsies.

• Donor search, HLA typing and harvest;

• Pre-transplant dental evaluation and treatment;

• Transplantation;

• Post-transplant care including but not limited to:

  • Laboratory studies;

  • X-ray and diagnostic imaging;

  • Biopsies;

  • Home health;

  • Skilled nursing facilities;

  • Medications;

  • Transportation, room and board for the transplant candidate, donor and one adult caregiver as identified by the transplant facility;

    • To and from medical treatment;

    • For the duration of time it is necessary for the member to remain in close proximity to the transplant center, which includes evaluation, ongoing testing, transplantation and post-transplant care by the transplant center.

For the Donor

Services are covered only when provided in the United States and are limited to the following:

• Evaluation and testing for suitability;

• Solid organ or hematopoietic stem cell procurement, processing, and storage;

• Transportation and lodging when it is necessary for potential donor to travel for testing to determine if they are a match and to donate either stem cells or organs.

DCS CHP and its contracted MCO coordinate with the AHCCCS Transplant Coordinator to determine coverage of services, and refers to the AHCCCS Specialty Contract for Transplantation Services on the AHCCCS website for detailed description of covered services. A reinsurance case is created in the AHCCCS health information system (PMMIS) with reference to processes in the AHCCCS Reinsurance Processing Manual. Written notification is sent to the AHCCCS Transplant Coordinator requesting transplant reinsurance.

Authorization Requests

Authorization of requests for transplant evaluations are processed within the same framework of Prior Authorization guidelines and time frames. Requests are addressed promptly or as expeditiously as the member’s condition requires.

Out of network coverage for transplants are reviewed with AHCCCS and determined on a case by case basis.

Each transplant case is closely monitored and tracked by the contracted MCO as well as the DCS CHP Transplant Coordinator to ensure quality, cost-effective care and improved outcomes for members with complicated, long-standing or specific medical needs. The member’s progress is monitored for attaining the expected outcomes, by maintaining communication with health care providers, custodial agency representatives, caregivers, MCO care management and other stakeholders, as deemed appropriate.

The Transplant Coordinator in coordination with the MCO’s care management staff assists the custodial agency representative in referring members to collateral agencies as necessary. Other clinical staff may assist in this process.

Reporting

A Transplant Tracking Log is forwarded to AHCCCS quarterly, listing all potential transplants awaiting services and those members who received transplants during the contract year.

All transplant cases are presented as de-identified data at the Medical Management (MM) and the Quality Management/Performance Improvement (QM/PI) Committee Meetings.