Solid Organ Transplant Benefits to Change for Texas Medicaid

Transcription

1 Slid Organ Transplant Benefits t Change fr Texas Medicaid Infrmatin psted February 13, 2015 Nte: All new and updated prcedure cdes and their assciated reimbursement rates are prpsed benefits pending a rate hearing and apprval f expenditures. Prviders will be ntified when the rates and expenditures are apprved. Nte: This article applies t claims submitted t TMHP fr prcessing. Fr claims prcessed by a Medicaid managed care rganizatin (MCO), prviders must refer t the MCO fr infrmatin abut benefits, limitatins, prir authrizatin, and reimbursement. Effective fr dates f services n r after April 1, 2015, slid rgan transplant benefits will change fr Texas Medicaid. Slid rgan transplants are a benefit f Texas Medicaid when medically necessary based n safety and efficacy, as demnstrated by scientific evidence and by cntrlled clinical studies, in accrdance with the Texas Administrative Cde (TAC). Cvered slid rgan transplants include: Heart Intestinal Kidney Liver Lung Pancreas r simultaneus kidney- pancreas Slid rgan transplants are limited t clients with a critical medical cnditin wh are expected t have a successful clinical utcme that will result in a return t imprved functinal independence. Expenses incurred fr prcurement f a living dnr s rgan are nt a benefit f Texas Medicaid. All slid rgan transplants must be perfrmed in a Medicaid enrlled facility that is certified by United Netwrk f Organ Sharing (UNOS) r designated as a Children s Hspital with a transplant unit r prgram. The facility must be in Texas, unless there are n Texas facilities certified by UNOS r designated as a Children s Hspital with a transplant unit r prgram fr the requested prcedure. All requests fr ut-f-state (OOS) services, whether fr pre-transplant evaluatin, transprtatin, r pst-transplant mnitring, must be sent t the medical directr fr prir authrizatin review. Texas Medicaid will cnsider authrizing OOS services when the fllwing criteria are met: The client des nt leave Texas t receive care that can be received in Texas. An in-state facility apprved fr the prcedure has declined t accept the client and dcumentatin is submitted t explain why the in-state team cannt perfrm the prcedure.

2 There is n physician prvider r facility with the level f expertise required t perfrm the necessary prcedure available in Texas, r the client has received an initial transplant at the OOS facility and requires additinal transplant services due t cmplicatins r graft lss. There is reasnable assurance that the client meets the clinical criteria required by Texas Medicaid fr transplant apprval. The service is necessary, reasnable, and federally allwable, and the facility and physicians agree t accept Medicaid reimbursement fr these services. Additinally, the OOS facility must be certified by UNOS r designated as a Children s Hspital with a transplant unit r prgram. When requesting an OOS prir authrizatin fr a pre-transplant evaluatin, the prvider must submit a cpy f the transplant evaluatin perfrmed by a Texas facility t supprt the need fr an OOS slid rgan pre-transplant evaluatin. When requesting an OOS prir authrizatin fr transplant f a slid rgan, the prvider must submit a cpy f the transplant evaluatin perfrmed by a Texas facility and a cpy f the transplant evaluatin perfrmed by the OOS facility t supprt the need fr an OOS slid rgan transplant. When requesting an OOS prir authrizatin fr pst-transplant mnitring r ther psttransplant services, the prvider must submit dcumentatin that the client received the initial transplant at the same OOS facility t include cmplicatins r graft lss if present, in rder t supprt the need fr OOS slid rgan pst-transplant mnitring r ther pst-transplant services. General Prir Authrizatin Requirements Slid rgan transplant prir authrizatin requests must include all f the fllwing: A cmplete histry and physical A statement f the current medical cnditins and status f the transplant recipient Dcumentatin f hw the client meets the prir authrizatin criteria specified fr the transplant requested Dcumentatin f the absence f c-mrbidities r cntraindicatins such as the fllwing: Severe pulmnary hypertensin End-stage cardiac, renal, hepatic, r ther rgan dysfunctin unrelated t the primary disrder Uncntrlled HIV infectin r AIDS defining illness Multiple rgan cmprmise secndary t infectin, malignancy, r cnditin with n knwn cure Onging r recurrent active infectins that are nt effectively treated Psychiatric instability severe enugh t jepardize incentive fr adherence t medical regimen

3 Active alchl r chemical dependency that might interfere with cmpliance t a medical regimen Histry f cmpliance with ther medical treatments, regimen, and plan f care Nte: Backbench prcedures d nt require prir authrizatin but may nly be reimbursed when a crrespnding transplant prcedure has been paid fr the same date f service. Additinal prir authrizatin changes, if applicable, specific t each type f transplant are utlined in the fllwing sectins. Nte: Clients wh are birth thrugh 20 years f age and wh d nt meet the criteria fr cverage may be cnsidered thrugh the Cmprehensive Care Prgram (CCP). Heart Transplants Assistant surgery prcedure cde will be a benefit fr nurse practitiners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs). Backbench prcedure cde will be a benefit when perfrmed in the inpatient hspital setting by a physician. Assistant surgery prcedure cde will als be payable t NPs, CNSs, and PAs. Prcedure cde may nly be reimbursed when prcedure cde has been paid fr the same date f service. Prir Authrizatin Criteria Prcedure cde may be cnsidered fr prir authrizatin with medical necessity dcumentatin that indicates a New Yrk Heart Assciatin (NYHA) Class III r IV cardiac disease with ne f the fllwing medical cnditins: Cngenital heart disease Valvular heart disease Viral cardimypathy Familial r restrictive cardimypathy Intestinal Transplants An intestinal transplant may be cnsidered fr clients wh are dependent n parental nutritin and have cmprmised venus access, have had tw r mre episdes f central line sepsis, r wh have begun t manifest prgressive parental nutritin assciated liver dysfunctin. Small bwel transplantatin may be cnsidered fr clients with irreversible intestinal failure including, but nt limited t: Shrt bwel syndrme Pseud-bstructin Micrvillus inclusin Tumr Assistant surgery prcedure cdes and will be a benefit when perfrmed in the inpatient hspital setting by a physician, NP, CNS, r PA.

4 Assistant surgery prcedure cdes 44715, 44720, and will be a benefit fr NPs, CNSs, and PAs. Prcedure cdes 44715, 44720, and may nly be reimbursed when prcedure cde has been paid fr the same date f service. Kidney Transplants Backbench prcedure cdes 50323, 50325, 50327, 50328, and may nly be reimbursed when prcedure cde 50360, 50365, r S2065 has been paid fr the same date f service. Prir Authrizatin Criteria Prcedure cdes and may be cnsidered fr prir authrizatin with medical necessity dcumentatin f ne f the fllwing: Hemdialysis r cntinuus ambulatry peritneal dialysis Chrnic renal failure with anticipated deteriratin t end-stage renal disease End-stage renal disease, evidenced by a creatinine clearance belw 20 ml/min r develpment f symptms f uremia End-stage renal disease that requires dialysis r is expected t require dialysis within the next 12- t 18-mnth perid Liver Transplants Transplant prcedure cde will be a benefit when prir authrized and perfrmed in the inpatient hspital setting by a physician. Backbench prcedure cdes 47143, 47144, 47145, 47146, and will be a benefit when perfrmed in the inpatient hspital setting by a physician. Assistant surgeries perfrmed fr the fllwing prcedure cdes will als be payable t NPs, CNSs, and PAs: Prcedure Cdes Backbench prcedure cdes 47143, 47144, 47145, 47146, and may be reimbursed nly when prcedure cde r has been paid fr the same date f service. Lung Transplants Transplant prcedure cde S2060 will be a benefit when prir authrized and perfrmed in the inpatient hspital setting by a physician. Backbench prcedure cdes and will be a benefit when perfrmed in the inpatient hspital setting by a physician. Assistant surgery prcedure cdes 32851, 32852, 32853, 32854, 32855, 32856, and S2060 will als be payable t NPs, CNSs, and PAs. Backbench prcedure cdes and may be reimbursed nly when prcedure cde S2060 has been paid fr the same date f service. Pancreas Transplants

5 Backbench prcedure cdes and will be a benefit when perfrmed in the inpatient hspital setting by a physician. Assistant surgery prcedure cdes and will als be payable t NPs, CNSs, and PAs. Prcedure cdes and may nly be reimbursed when prcedure cde r S2065 has been paid fr the same date f service. Prcedure cde will n lnger be a benefit in the utpatient hspital setting. Prir Authrizatin Criteria Prcedure cdes and may be cnsidered fr prir authrizatin with medical necessity dcumentatin that includes the fllwing: Recurrent, acute, and severe metablic and ptentially life-threatening cmplicatins requiring medical attentins such as: Hypglycemia Hyperglycemia Ketacidsis Failure f exgenus insulin-based management t achieve sufficient glycemic cntrl (HbA1c f greater than 8.0) despite aggressive cnventinal therapy Insensibility t hypglycemia; OR Satisfactry kidney functin (creatinine clearance greater than 40mL/min), except fr kidney-pancreas transplants; and Type 1 diabetes with secndary diabetic cmplicatins that are prgressive despite the best medical management; and At least tw f the fllwing secndary cmplicatins: Diabetic neurpathy Retinpathy Gastrparesis Autnmic neurpathy Extremely labile (brittle) insulin-dependent diabetes mellitus Multi-Organ Transplants Prcedure cde S2053 will n lnger be age restricted. Prcedure cdes 33933, S2054, and S2065 will be a benefit when perfrmed in the inpatient hspital setting by a physician. Assistant surgery prcedure cdes 33933, 33935, S2054, and S2065 will als be payable t NPs, CNSs, and PAs. Backbench prcedure cde may be reimbursed nly when prcedure cde has been paid fr the same date f service. Prir Authrizatin Criteria Prcedure cdes 33935, S2053, and S2054 may be cnsidered fr prir authrizatin if medical necessity dcumentatin meets the requirements fr each rgan.

6 Prcedure cde S2065 may be cnsidered fr prir authrizatin if medical necessity dcumentatin indicates the client meets criteria fr a pancreas transplant and has endstage renal disease that requires dialysis r is expected t require dialysis within the next 12 mnths. Fr mre infrmatin, call the TMHP Cntact Center at