Centene Transplant Documentation Prior Auth Update

Coverage Criteria

Documentation-based medical necessity criteria for evaluation and listing

Covered when ALL of the following documentation requirements are met for the relevant request type:

General requirements for transplant evaluation: Appropriate prior authorization form and complete history and physical within one year for evaluation requests.history & physical within 1 year for evaluation

Evaluation approvals effective for six months.

Listing requirements (initial and subsequent) for autologous or allogeneic stem cell and solid organ: Appropriate prior authorization form; letter of medical necessity from a transplant service provider with signature; complete history and physical performed by a transplant service provider within 12 months for kidney transplant requests or within six months for other transplant requests; complete chemistry panel, liver function tests, and complete blood count within 12 months for kidney transplants or six months for other transplants; organ-specific testing and documentation as listed (liver: INR, MELD/PELD, hepatitis serologies, imaging, biopsy as indicated; kidney: GFR or creatinine clearance if not on dialysis; heart: echocardiogram, right heart catheterization including PVR, NYHA class and peak VO2; lung: PFTs, chest x‑ray/CT, six‑minute walk; pancreas: history of insulin treatment; intestine/multivisceral: documentation of failed TPN; stem cell: most recent bone marrow biopsy as indicated, most recent ECOG or Karnofsky score, lumbar puncture if indicated, and donor identification for allogeneic transplants).organ-specific tests as listed

Listing approvals effective for 12 months.

Infectious disease and screening requirements: CMV and VZV within one year unless baseline IgG antibody positive; EBV within one year unless baseline IgG antibody positive; toxoplasma titer for heart transplant recipients; annual PPD/T‑Spot/QuantiFERON for solid organ transplants unless previously positive; hepatitis B and hepatitis C testing within one year unless baseline positive (if baseline positive then viral load within three months); RPR within one year; HIV within one year unless baseline positive (if baseline positive then CD4 and viral load within three months).recency and follow-up viral load/CD4 when baseline positive

Other requirements: Annual dental evaluation and clearance (transplant clearance from DDS or panoramic dental x‑ray with MD clearance); routine health screening per standards of care; appropriate comorbidity testing/clearance; cardiology testing/clearance including echocardiogram and EKG as indicated; serum or urine drug screen within 90 days of request; detailed psychosocial evaluation and clearance within 12 months for kidney transplants and six months for other transplants.drug screen within 90 days; psychosocial recency by organ as specified

Post‑transplant follow‑up visits require prior authorization and submission of discharge summary or H&P from the transplant admission.

Multiple facility/additional evaluation coverage

Additional covered circumstances for authorization at multiple facilities or additional evaluations:

Criteria for additional/transfers: Authorization for transplant services at multiple facilities or for additional evaluations is medically necessary when the member has an episode of illness resulting in a change to transplant eligibility status OR the member is admitted to a geographically closer facility and is not stable for transfer to the previously approved facility due to declining medical status.

This policy does not apply to certain specialized autologous transplant procedures. Specifically, corneal transplant, pancreatic islet cell auto‑transplant after pancreatectomy, and parathyroid auto‑transplant after thyroidectomy are excluded from the documentation requirements in this clinical policy. Requests for these services require completion of the Health Plan–specific prior authorization form available on the Health Plan website.

Coverage determinations under this clinical policy are subject to the terms, exclusions, limitations and conditions of the member's contract of insurance (for example, evidence of coverage, certificate of coverage, or contract of insurance). Decisions must also comply with applicable state and federal requirements and any Health Plan–level administrative policies and procedures. Where state Medicaid provisions conflict with this clinical policy, the applicable state Medicaid provisions take precedence.

This clinical policy is a guide to medical necessity and does not constitute a guarantee of payment; providers must exercise clinical judgment and ensure services meet all contractual and regulatory requirements prior to authorization or claim submission.

Requests that do not include the required clinical documentation elements identified in the policy (for example, the appropriate prior authorization form, a complete history and physical within the specified timeframe, necessary laboratory testing, infectious disease screening, psychosocial evaluation, organ‑specific testing, or other listed items) do not meet medical necessity for transplant evaluation or listing and may be denied.

Coding

Referenced CPTCPT

CPT referenced

CPT codes are referenced for informational purposes; specific codes not listed in this portion of the document.

inv-07: Serum or urine drug screen recency — within 90 days.

Required timingSerum or urine drug screen results must be documented within 90 days of the request.

Applies toAll evaluation and listing requests (solid organ and stem cell) and associated documentation requirements.

Documentation contextIncluded as part of the required laboratory testing for transplant evaluation/listing per policy criteria.

inv-08: History & physical/lab recency by organ — 12 months for kidney; 6 months for other transplants.

Kidney transplantsComplete history & physical and required labs must be performed within 12 months of the request.

Other transplants (non‑kidney)Complete history & physical and required labs must be performed within 6 months of the request.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for transplant evaluations, transplant listing requests, and post‑transplant follow‑up office visits. Inpatient transplant admissions require a separate authorization from evaluation, listing, or follow‑up authorizations.

Prior authorization required for transplant evaluation, listing, and post‑transplant follow‑up office visits
Inpatient transplant admissions require separate authorization

Prior Authorization

Align with Medicare NCDs/LCDs

For Medicare members/enrollees, providers must review and align requests and documentation with applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying this policy's criteria.

Review applicable NCDs, LCDs, and Medicare Coverage Articles (CMS website) when servicing Medicare members
Coverage decisions for Medicare members must be consistent with applicable Medicare guidance

Organ- and Transplant-Specific Candidate Documentation

Organ-/transplant-specific candidate documentation

Candidate evaluation requires organ- and transplant-type specific data and assessments:

Liver-specific: International normalized ratio (INR); MELD or PELD score; hepatitis serologies; appropriate imaging studies (MRI, CT, ultrasound); liver biopsy when indicated.

Kidney-specific: Glomerular filtration rate (GFR) or creatinine clearance if not on dialysis.

Heart-specific: Echocardiogram; right heart catheterization results including pulmonary vascular resistance (PVR); NYHA functional class; peak VO2 results.

Lung-specific: Pulmonary function tests (PFTs); chest x‑ray and/or CT imaging; six‑minute walk test.

Evaluation Requirements

Note

Complete required evaluation components and testing

Complete a thorough history and physical and ensure all organ‑specific testing, infectious disease screening, psychosocial evaluation, dental clearance, and routine health maintenance documentation are included per the policy before submission.

H&P: within 12 months for kidney or 6 months for other transplants
Organ‑specific testing: e.g., MELD/INR/liver imaging, GFR for kidney, echo/right heart cath for heart, PFTs and 6‑minute walk for lung
Infectious disease screening and annual dental clearance as specified

Prior Authorization

Request separate authorization for transplant admissions and confirm center requirements

Transplant inpatient admissions require a separate prior authorization and are not covered by evaluation/listing authorizations; follow the plan's prior authorization process for transplant admissions and verify center accreditation/certification requirements as applicable.

Submit separate authorization for transplant admission
Confirm center accreditation/certification requirements per plan

Post-Transplant Follow-Up Coverage

inv-26: post-transplant follow-up office visit — requires prior authorization and documentation (discharge summary or history, operative reports, medication list, lab results).

Prior authorization requiredPost‑transplant follow‑up office visits require an appropriate prior authorization form before the visit is covered.

Required documentationSubmission must include the discharge summary or the history & physical from the inpatient hospital stay for the transplant admission.

Where to checkFor authorization requirements for services unrelated to post‑transplant follow‑up visits, check the health plan's prior authorization tool.

Definitions

inv-20: Autologous and Allogeneic HCT definitions.

Autologous HCTUse of a patient’s own hematopoietic cells to rebuild bone marrow following intensive chemotherapy and/or radiation therapy; evaluation includes comorbidity assessment, clinical/laboratory testing, infectious disease screening, cardiac and pulmonary assessments, and bone marrow/CNS evaluation.

Allogeneic HCTUse of hematopoietic cells from another person (e.g., sibling, relative, volunteer donor, umbilical cord blood) to treat hematologic cancers and nonmalignant marrow disorders; eligibility varies by institution and includes disease status, comorbidities, and donor identification.

Functional assessmentAssessment of functional status is recommended using ECOG or Karnofsky performance status as part of pretransplant evaluation.

inv-21: Scoring systems and performance status (MELD/PELD, ECOG/Karnofsky).

MELD/PELDModel for End‑Stage Liver Disease (MELD) or Pediatric End‑Stage Liver Disease (PELD) scores are used to assess severity for liver transplant candidates (listed under liver-specific testing).

Background

Pre‑transplant evaluations are performed to identify medical and psychosocial conditions that may affect transplant success. These assessments review overall health, disease severity and stage, infectious exposures, organ function, comorbid conditions, and functional status. Both solid organ and hematopoietic cell transplantation candidates require organ‑ and disease‑specific testing, performance status assessment, and psychosocial evaluation because recipients face lifelong immunosuppression and elevated risks of infection and malignancy. Note: the background content in this policy was updated for clarity and does not change the coverage criteria.

Contraindications

No contraindications are specified in this portion of the clinical policy.

Coding and Operational Notes

Note

Operational reminder: coverage depends on member contract and laws

Confirm coverage is subject to the member contract, state and federal rules, and plan administrative policies; verify member benefits and applicable regulatory requirements before proceeding.

OpenPayer

Transplant Service Documentation Requirements

Coverage Criteria

Coding

Provider Actions and Requirements

Organ- and Transplant-Specific Candidate Documentation

Evaluation Requirements

Post-Transplant Follow-Up Coverage

Definitions

Background

Contraindications

Coding and Operational Notes