CurrentCentenePolicy CP.MP.247

Transplant Service Documentation Requirements

Defines required clinical documentation and timeframe requirements for transplant evaluation requests, transplant listing requests, post-transplant follow-up office visits, continuity of care authorizations, and circumstances for additional authorizations across all solid organ and stem cell/bone marrow transplants for health plans affiliated with Centene.

Policy Summary

PayerCentene

PolicyTransplant Service Documentation Requirements

Policy CodePolicy CP.MP.247

Change TypeRevisions and additions (criteria, timeframes, post-transplant visit requirements)

Effective Date

Next Review Date

Key ActionProviders must submit the appropriate prior authorization form for evaluation, listing, post-transplant follow-up office visits, and other transplant-related requests as specified.

SourceLink

POLICY UPDATE CHANGES

Clarified applicability to evaluation and listing requests; transplant admissions require separate authorization. (Revision logged 02/25)

Added requirements for post-transplant follow up office visits and a note regarding other requests. (Revision Date = 03/25)

Adjusted time requirements: 12 months for kidney transplants and 6 months for other transplants for certain documentation elements. (Change originally made 11/22 and reiterated 12/22 and 11/23)

Minor rewording and administrative updates with no impact on criteria; background and references updated. (Multiple annual reviews; latest 10/24 background updates only)

All solid organ & stem cellCovered Indications

6 mo

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Evaluation authorization duration

12 moListing authorization duration

90 daysDrug screen validity

Coverage Summary

This policy (CP.MP.247) applies to all solid organ and stem cell/bone marrow transplant evaluation and listing requests for health plans affiliated with Centene and defines required clinical documentation and timeframe requirements for coverage. Transplant evaluation and listing requests are covered with specific documentation criteria; transplant admissions require separate authorization. Approved transplant evaluation authorizations are effective for 6 months, and approved transplant listing authorizations are effective for 12 months, after which a new authorization with updated clinical documentation is required.

Thresholds / Timing Requirements (source wording)

Transplant evaluation authorization validity6 months (approved requests effective for six months)

Transplant listing authorization validity12 months (approved listings effective for 12 months)

Complete history & physical timing - kidneywithin 12 months

Complete history & physical timing - other transplantswithin 6 months

Basic labs timing - kidneywithin 12 months (complete chemistry/LFTs and CBC)

Basic labs timing - other transplantswithin 6 months (complete chemistry/LFTs and CBC)

Psychosocial evaluation timingwithin 12 months for kidney and within 6 months for other transplants

Serum or urine drug screen validitywithin 90 days of request

Infectious disease serologies timing (general)within 1 year unless baseline antibody/previous positive exceptions apply

Hepatitis C when antibody positiveviral load required within 3 months

HIV when antibody/diagnosis positiveCD4 count and viral load required within 3 months

Medical Necessity Criteria

I. Transplant evaluation requests (medical necessity when ALL included)

Covered when ALL of the following are met:

ALL of the following

Appropriate prior authorization form
Routine complete history and physical within one year including: history of present illness, including a list of all current medications; past medical history, pertinent family history and social history; complete review of systems, physical examination, including height, weight and body mass index (BMI)
Routine complete history and physical within one year
Operational timeframe: Approved requests for transplant evaluation are effective for six months; after six months a new authorization is required

I.B. Initial and subsequent transplant listing requests (ALL required)

Provider Actions & Requirements

Prior Authorization

Submit appropriate prior authorization form

Providers must submit the appropriate prior authorization form for evaluation, listing, post-transplant follow-up office visits, and other transplant-related requests so the request can be evaluated.

Documentation Required

Include complete history and physical and required testing

Include a routine complete history and physical and required testing with evaluation and listing requests. Required elements: H&P with history of present illness and list of current medications; past medical, family and social history; complete review of systems and physical exam including height, weight and BMI. Basic labs (CBC and chemistry/LFTs) within 12 months for kidney transplants or within 6 months for other transplants. Transplant-specific testing and imaging as indicated (e.g., liver INR/MELD/PELD and imaging, kidney GFR/creatinine clearance, heart echo/right cath/PVR/NYHA/peak VO2, lung PFTs/chest imaging/6-minute walk, pancreas BMI/insulin history, intestine documentation of failed TPN, stem cell bone marrow biopsy and ECOG/Karnofsky and donor ID). Annual dental clearance, routine screening exams, comorbidity testing (including cardiology), serum/urine drug screen within 90 days, infectious disease screening within 1 year as applicable (CMV, VZV, EBV, toxoplasma for heart, PPD/T-Spot/QuantiFERON, hepatitis B and C, RPR, HIV with CD4/viral load when positive). Detailed psychosocial evaluation and clearance within 12 months for kidney transplants and within 6 months for other transplants.

Referenced Coding

Referenced coding (informational only)CPT

No codes listed

Background

The pre-transplant evaluation is intended to identify conditions and risks that can affect transplant success and postoperative recovery; it encompasses diagnostic tests and consultations necessary to assess transplant candidacy. National data show rising transplant volumes—over 41,000 organ transplants in 2021 with continued increases into 2023 and more than 105,000 people on the national transplant waiting list—highlighting the importance of comprehensive evaluation and donor-recipient matching.

Pretransplant assessments must evaluate infectious disease risk and exposure history, serologic testing, cultures to identify colonization, and vaccination status because established infections are harder to treat after immunosuppression. Functional and performance assessments (e.g., ECOG or Karnofsky scores) and organ-specific testing (cardiac, pulmonary, imaging, labs) are integral to determining candidacy and estimating peri- and post-transplant risk.

Stem cell/bone marrow transplant evaluations differ by transplant type: autologous HCT focuses on assessment of comorbid conditions, disease status, clinical and laboratory assessments, infectious disease screening, cardiac and pulmonary evaluation, bone marrow/CNS evaluation, and functional status; allogeneic HCT requires a detailed history/physical, chest x-ray, ECG, pulmonary function tests, cardiac function studies, laboratory testing including prior infectious exposures, and use of established risk scoring (e.g., EBMT, HCT-CI) to inform eligibility and counseling.

Medicare National Coverage Determinations

NCD Number	Name	Effective Date	Type
260.1	Adult liver transplantation	2012-06-21	NCD
260.2	Pediatric liver transplantation	1991-04-12	NCD
260.9	Heart transplants	2008-05-01	NCD
260.3	Pancreas transplants	2006-04-26	NCD
260.5	Intestinal and multi-visceral transplantation	2006-05-11	NCD
110.23	Stem cell transplantation (formerly 110.8.1)	2024-03-06	NCD

Revision History

03/25revision (material)Latest

Added requirements for post-transplant follow up visits and a note regarding other requests; Approval Date = 03/25. (Material change)

02/25revision (material)

Clarified that the policy applies to transplant evaluation and listing requests and added that transplant admissions require separate authorization. (Material change)

11/22original revision (material)

Policy Summary

PayerCentene

PolicyTransplant Service Documentation Requirements

Policy CodePolicy CP.MP.247

Change TypeRevisions and additions (criteria, timeframes, post-transplant visit requirements)

Effective Date

Next Review Date

Key ActionProviders must submit the appropriate prior authorization form for evaluation, listing, post-transplant follow-up office visits, and other transplant-related requests as specified.

SourceLink

On This Page

Covered when ALL of the following are met:

ALL of the following

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, including history of present illness with current medications, past medical history, pertinent family and social history, complete review of systems, physical exam including height, weight and BMI
Basic labs (complete chemistry panel/liver function tests and complete blood count) within 12 months for kidney transplants or six months for other transplants
Appropriate testing, imaging, and documentation for the requested transplant (examples: 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, imaging, six-minute walk test; pancreas — BMI and insulin treatment history; intestine/multivisceral — documentation of failed TPN; stem cell — most recent bone marrow biopsy as indicated, most recent ECOG or Karnofsky score, and donor identification for allogeneic transplants)
Annual dental evaluation and clearance (transplant clearance from DDS or panoramic dental x-ray with MD clearance)
Routine health screening exams per standards of care (e.g., mammogram, Pap, and/or colonoscopy) — these particular screenings are not required for autologous stem cell transplant
Appropriate comorbidity testing/clearance, including cardiology
Serum or urine drug screen results within 90 days of request
Infectious disease screening for solid organ or allogeneic stem cell transplant — ALL applicable tests as indicated: CMV and VZV within one year unless baseline IgG antibody positive; EBV within one year unless baseline IgG antibody positive; Toxoplasma titer for heart recipients; annual PPD/T-Spot/QuantiFERON unless previously positive; Hepatitis B within one year unless baseline surface antibody positive; Hepatitis C within one year unless baseline positive (viral load within three months if positive); RPR within one year; HIV within one year unless baseline positive (CD4 count and viral load within three months if positive)
Detailed psychosocial evaluation and clearance within 12 months for kidney transplants and six months for other transplants
Operational timeframe: Approved requests for transplant listings are effective for 12 months; after 12 months a new authorization with updated clinical documentation is required. Operational requirement: Inpatient admissions for transplants require separate authorization from evaluation or listing authorizations.

I.C. Post-transplant follow-up office visits (ALL required)

Covered when ALL of the following are met:

ALL of the following

Appropriate prior authorization form
Discharge summary or history and physical from the inpatient hospital stay for the transplant admission
Note: For authorization requirements for services unrelated to post-transplant follow up office-visits, check the health plan's prior authorization tool
Operational guidance

I.D. Continuity of care authorizations (ALL required)

Covered when ALL of the following are met:

ALL of the following

Documentation of previous insurer coverage (e.g., previously covered by state Medicaid fee for service)
Documentation of authorization for coverage of transplant evaluation or listings by previous insurer
Copy of United Network for Organ Sharing (UNOS) listing

II. Additional authorizations for multiple facilities or additional evaluations

Authorizations considered medically necessary when ANY of the following are met:

ANY of the following

Member/enrollee has an episode of illness resulting in a change to transplant eligibility status
Member/enrollee is admitted to a geographically closer facility and is not stable for transfer to the previously approved facility due to declining medical status

Documentation Required

Provide letter of medical necessity for listing

Provide a signed letter of medical necessity from a transplant service provider with listing requests. The letter of medical necessity must be included for initial and subsequent transplant listing requests.

Prior Authorization

Reauthorize after expiration

Obtain a new authorization after the prior approval expires: transplant evaluation authorizations are effective for six months and require a new authorization after six months; transplant listing authorizations are effective for 12 months and require a new authorization with updated clinical documentation after 12 months.

Documentation Required

Provide inpatient discharge summary for post-transplant visits

Submit the inpatient discharge summary or history and physical from the transplant hospital stay when requesting authorization for post-transplant follow-up office visits.

Documentation Required

Provide continuity of care documentation

For continuity of care authorizations provide documentation of prior coverage and authorization and evidence of listing: documentation of previous insurer coverage (e.g., previously covered by state Medicaid fee for service), documentation of authorization for coverage of transplant evaluation or listings by the previous insurer, and a copy of the UNOS listing.

Prior Authorization

Separate authorization for transplant admissions

Obtain a separate authorization for inpatient transplant admissions. Inpatient transplant admissions require a separate prior authorization and are not covered by evaluation or listing authorizations.

New policy created; adjusted time requirements to 12 months for kidney transplants and 6 months for other transplants for certain documentation elements. (Material change)

12/22reiteration/approval (material)

Adjustment from 11/22 reiterated: time requirements of 12 months for kidney and 6 months for other transplants and added 'with updated clinical documentation' to listing note. (Material change)

11/23annual review (material)

Annual review with minor rewording and updates; criteria clarified and documentation items updated; Approval Date = 11/23. (Material change)

11/23annual review (non-material background updates)

Annual review: Background updated with no impact on criteria; references reviewed and updated. (Non-material)

10/24annual review (non-material)

Annual review: Background updated with no impact on criteria; references reviewed and updated. Latest review 10/24 states background updates only. (Non-material)