MEDICAL MANAGEMENT POLICY

Size: px

Start display at page:

Download "MEDICAL MANAGEMENT POLICY"

Nicholas Dalton
5 years ago
Views:

1 PAGE: 1 of 5 MEDICAL MANAGEMENT POLICY This medical policy is not a guarantee of benefits or coverage, nor should it be deemed as medical advice. In the event of any conflict concerning benefit coverage, the employer/member summary plan document (SPD) supersedes this medical policy. DEFINITIONS: Organ transplantation is an established treatment for the failure of vital organs. Organ and bone marrow transplant is essential to replace organs or cells damaged by end-stage diseases with a donor s healthy organ or cells. The purpose of transplantation is to improve or lengthen the quality of one s life. INDICATIONS: Transplants are for the purposes of maintaining the purposeful integrity of tissues or organs in the recipient. Organ transplants are procedures used to treat life-threatening complications resulting from end-stage organ diseases and malignant conditions. POLICY: Coverage will be provided for transplants when they are determined to be medically necessary. MHealth makes coverage decisions in accordance with Medicare guidelines unless superseded by operational policies. PROCESS: The member or provider must contact: 1. The Customer Service department to verify eligibility/benefits. 2. Medical Management to initiate a pre-authorization. 3. Provide clinical information which supports the medical necessity of the requested service. CPT, HCPC CODES: (Note the codes below are not all-inclusive and MHealth does follow Medicare Guidelines.) Punch graft for hair transplant; one (1) to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts 2344 Resection or transplantation of long tendon of biceps Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon 1

2 PAGE: 2 of 5 MEDICAL MANAGEMENT POLICY CPT, HCPC CODES: (Note the codes below are not all-inclusive and MHealth does follow Medicare Guidelines.) Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon Transfer or transplant of tendon, palmar; without free tendon graft, each tendon Transfer or transplant of tendon, palmar;with free tendon graft (includes obtaining graft), each tendon Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); single tendon Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); multiple tendons Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot) Transfer or transplant of single tendon (with muscle redirection or rerouting);deep (e.g., anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (list separately in addition to code for primary procedure) Arthroscopy, knee, surgical;meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral Lung transplant, single; without cardiopulmonary bypass Lung transplant, single; with cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral Management of recipient hematopoietic progenitor cell donor search and cell acquisition Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing 2

3 PAGE: 3 of 5 MEMD (Note the codes below are not all-inclusive and MHealth does follow Medicare Guidelines.) Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing Transplant preparation of hematopoietic progenitor cells;specific cell depletion within harvest, T-cell depletion Transplant preparation of hematopoietic progenitor cells; tumor cell depletion Transplant preparation of hematopoietic progenitor cells; red blood cell removal Transplant preparation of hematopoietic progenitor cells; platelet depletion Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer Bone marrow harvesting for transplantation Bone marrow or blood-derived peripheral stem cell transplantation; allogenic Bone marrow or blood-derived peripheral stem cell transplantation; autologous Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions Intestinal allotransplantation; from cadaver donor Intestinal allotransplantation; from living donor Removal of transplanted intestinal allograft, complete Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, without trisegment or lobe split Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, with trisegment split of whole liver graft into two (2) partial liver grafts (i.e., left lateral segment [segments II and III] and right trisegment (segments I and IV through VIII)) 3

4 PAGE: 4 of 5 (Note the codes below are not all-inclusive and MHealth does follow Medicare Guidelines) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, with lobe split of whole liver graft into two (2) partial liver grafts (i.e., left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII]) Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft Unlisted procedure, pancreas Renal allotransplantation, implantation of graft; without recipient nephrectomy Renal allotransplantation, implantation of graft; with recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation, reimplantation of kidney Ureterostomy, transplantation of ureter to skin Transplantation of testis(es) to thigh (because of scrotal destruction) Parathyroid autotransplantation (list separately in addition to code for primary procedure) Keratoplasty (corneal transplant); anterior lamellar Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) Keratoplasty (corneal transplant); penetrating (in aphakia) Keratoplasty (corneal transplant); penetrating (in pseudophakia) Keratoplasty (corneal transplant); endothelial Backbench preparation of corneal endothelial allograft prior to transplantation (list separately in addition to code for primary procedure) 4

5 PAGE: 5 of 5 (Note the codes below are not all-inclusive and MHealth does follow Medicare Guidelines) Ocular surface reconstruction; amniotic membrane transplantation Ocular surface reconstruction; limbal stem cell allograft (e.g., cadaveric or living donor) Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) Donor enterectomy (including cold preservation), open; from cadaver donor Donor enterectomy (including cold preservation), open; partial, from living donor Intestinal allotransplantation; from cadaver donor Intestinal allotransplantation; from living donor Removal of transplanted intestinal allograft, complete Parathyroid autotransplantation S2102 Islet cell tissue transplant from pancreas; allogeneic S2103 Adrenal tissue transplant to brain S2150 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation S2152 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies S2053 Transplantation of small intestine and liver allografts S2054 Transplantation of multivisceral organs S2055 Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor S2060 Lobar lung transplantation S2061 Donor lobectomy (lung) for transplantation, living donor S2065 Simultaneous pancreas kidney transplantation G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion G0342 Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion G0343 Laparotomy for islet cell transplant, includes portal vein catheterization and infusion 5

Original Policy Date

MP 7.03.02 Small Bowel/Liver and Multivisceral Transplant Medical Policy Section Surgery Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed with literature search/12/2013 Return