CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.247

Transplant Service Documentation Requirements

Defines required clinical documentation and prior authorization elements for transplant candidate evaluations, transplant listing requests, post-transplant follow-up visits, and continuity of care authorizations for liver, kidney, heart, and lung transplants for health plans affiliated with Centene Corporation.

Policy Summary

PayerCommunity Health Plan Washington

PolicyTransplant Service Documentation Requirements

Policy CodePolicy MC.CP.MP.247

Change TypeClarified; Added; Revised

Effective Date

Next Review Date

Key ActionProviders must submit the appropriate prior authorization form for transplant evaluations, listings, post-transplant follow-up visits, and continuity of care requests.

SourceLink

POLICY UPDATE CHANGES

Annual review: description, background, and references updated with no impact on criteria (02/24 and 10/24).

Added that transplant admissions require separate authorization; added requirements for post-transplant follow up visits (03/25).

Clarified that the policy applies to transplant evaluation and listing requests.

4Solid organs covered

12Required listing elements (approx)

6 monthsEvaluation auth duration

Listing auth duration

Coverage Summary

This policy (MC.CP.MP.247) applies to documentation requirements for transplant candidate evaluations, transplant listing requests, and post-transplant follow-up visits and is covered_with_criteria. It defines required clinical documentation and prior authorization elements for solid organ transplants involving the liver, kidney, heart, and lung.

Key thresholds and durations from policy

Authorization validity - evaluation6 months

Authorization validity - listing12 months

Drug screen recencyWithin 90 days of request

Infectious disease serology recencyWithin 1 year unless baseline antibody positive; if hepatitis C positive, viral load within 3 months; if HIV positive, CD4 count and viral load within 3 months

Solid organs covered in criteriaLiver, kidney, heart, lung (4)

Required documentation elements for listing (count)12

Medical-Necessity Criteria

Transplant evaluation requests (medically necessary when ALL are included)

For transplant evaluation requests, all the following:

ALL of the following

Appropriate prior authorization form
History and physical must include
- 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)

Provider Actions & Authorization Requirements

Prior Authorization

Submit appropriate prior authorization form

Submit the appropriate prior authorization form for transplant evaluations, transplant listings, post-transplant follow-up visits, and continuity of care requests.

Documentation Required

Provide complete H&P and supporting documentation

Provide a complete history and physical and supporting documentation as specified for evaluation and listing requests.

History of present illness, including a list of all current medications
Past medical history, pertinent family history and social history
Complete review of systems and physical examination, including height, weight, and BMI

Coding

Referenced coding (informational)mixed

No codes listed

Background

The pre-transplant evaluation identifies conditions that affect transplant candidacy and outcomes and includes covered diagnostic tests and consultations necessary to assess transplant suitability.

The policy aligns with the KDIGO, ISHLT, and UNOS guidelines referenced in the criteria and uses those sources to inform required testing, screening, and evaluation components.

To ensure safety and effectiveness, clinical assessments must be up-to-date (typically within 12 months) as specified in the criteria, and transplant admission requests require separate prior authorization per plan-adopted guidelines.

These requirements and timelines apply to evaluations and listings for liver, kidney, heart, and lung transplant recipients.

UNOS: United Network for Organ Sharing (UNOS) is cited as a source for transplant policy and program guidance used in the criteria and is the accepted national body referenced for listing and organ-specific guidance.

MELD/PELD: The Model for End Stage Liver Disease (MELD) and Pediatric End Stage Liver Disease (PELD) scores are specified as required liver transplant metrics (e.g., MELD/PELD score and INR) when applicable for liver transplant evaluation and listing.

Medicare National Coverage Determinations (NCDs)

Effective Date	Name	Number	Type
2012-06-21
Adult liver transplantation
260.1
NCD

Revision History

03/25clarified

Clarified in description that the policy applies to transplant evaluation and listing requests. (is_material: false)

03/25addedLatest

Added that transplant admissions require separate authorization. (is_material: true)

02/24revised

Annual review updates to description, background, and references with no impact on criteria noted (02/24 and 10/24). (is_material: false)

Policy Summary

PayerCommunity Health Plan Washington

PolicyTransplant Service Documentation Requirements

Policy CodePolicy MC.CP.MP.247

Change TypeClarified; Added; Revised

Effective Date

Next Review Date

Key ActionProviders must submit the appropriate prior authorization form for transplant evaluations, listings, post-transplant follow-up visits, and continuity of care requests.

SourceLink

On This Page

Note: Approved requests for transplant evaluation are effective for six months. After six months a new authorization is required.6 months

operational

Initial and subsequent transplant listing requests (all required)

For initial and subsequent transplant listing requests, all the following:

ALL of the following

Appropriate prior authorization form
Letter of medical necessity from a transplant service provider with signature
History and physical must include
- 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 BMI
Basic labs (complete chemistry panel/liver function tests and complete blood count) within 12 monthswithin 12 months
Transplant-specific tests (as applicable)
- Liver: International normalized ratio (INR), Model for End Stage Liver Disease (MELD) or Pediatric End Stage Liver Disease Model (PELD) score and liver biopsy as indicated
- Kidney: Glomerular filtration rate (GFR) or creatinine clearance if not on dialysis
- Heart: Echocardiogram, right cardiac catheterization results, including pulmonary vascular resistance (PVR) results; NYHA Class and peak VO2 results
- Lung: Pulmonary function tests, imaging (chest x-rays and/or CT scans), and six-minute walk test
Annual dental evaluation and clearance (transplant clearance from DDS or a panoramic dental x-ray with clearance from MD)
Routine health screening exams as per standards of care (e.g., mammogram, Pap, and/or colonoscopy)
Appropriate comorbidity testing/clearance, including cardiology
Serum or urine drug screen results (within 90 days of request)within 90 days
Infectious disease screening components
- Cytomegalovirus (CMV) and Varicella-zoster virus (VZV) within one year unless baseline IgG antibody positivewithin 1 year
- EBV (Epstein Barr virus) within one year, unless baseline IgG antibody positivewithin 1 year
- Toxoplasma titer for heart transplant recipients
- Results of annual purified protein derivative (PPD), T-Spot, or QuantiFERON for all solid organ transplants, unless previously positiveannual
- Hepatitis B testing within one year, unless baseline surface antibody positive
Detailed psychosocial evaluation and clearance within 12 monthswithin 12 months
Note: Approved requests for transplant listings are effective for 12 months. After 12 months a new authorization with updated clinical documentation is required.12 months
operational
Note: Inpatient admissions for transplants require separate authorization from evaluation or listing authorizations.
operational

Post-transplant follow-up office visits (all required)

For post-transplant follow up office visits, all the following:

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

Continuity of care authorizations (all required)

Requests for continuity of care authorizations, all the following:

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

Authorizations for additional evaluations or multiple facilities (medically necessary if either condition met)

Authorizations for transplant services at multiple facilities for a single member/enrollee or requests for additional evaluations following transplant listing are considered medically necessary for either:

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

Letter of medical necessity from a transplant service provider with signature

Basic labs (complete chemistry panel/liver function tests and complete blood count) within 12 months

Transplant-specific testing and imaging as applicable (e.g., INR/MELD/PELD/liver biopsy; GFR/creatinine clearance; echocardiogram/right heart cath/NYHA/peak VO2; PFTs/chest imaging/six-minute walk)

Annual dental evaluation and clearance (transplant clearance from DDS or panoramic dental x-ray with MD clearance)

Routine health screening exams (e.g., mammogram, Pap, colonoscopy)

Detailed psychosocial evaluation and clearance within 12 months

Documentation Required

Maintain timely infectious disease and drug screening results

Maintain up-to-date infectious disease serologies and drug screen results per policy recency rules; include documentation for baseline positives and additional testing when indicated.

CMV and VZV: within one year unless baseline IgG antibody positive
EBV: within one year unless baseline IgG antibody positive
PPD/T-Spot/QuantiFERON: annual result unless previously positive
Hepatitis B testing: within one year unless baseline surface antibody positive
Hepatitis C: within one year unless baseline positive (if positive, viral load required within 3 months)
RPR: within one year
HIV: within one year unless baseline positive (if positive, CD4 count and viral load required within 3 months)
Serum or urine drug screen: within 90 days of request

Prior Authorization

Re-authorize after expiration

Re-authorize after the approval period expires: evaluation authorizations are effective for 6 months and listing authorizations are effective for 12 months. Note that inpatient transplant admissions require a separate authorization.

Documentation Required

Continuity of care evidence

For continuity of care requests, provide evidence of prior coverage and approvals to support the request.

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

10/24revised

Annual review updates to description, background, and references with no impact on criteria noted (02/24 and 10/24). (is_material: false)

Hepatitis C within one year unless baseline positive (viral load required within three months if positive)within 1 year; viral load within 3 months if positive

Rapid plasma reagin (RPR) within one yearwithin 1 year

Human immunodeficiency virus (HIV) within one year, unless baseline positive (CD4 count and viral load required within three months if positive)within 1 year; CD4/viral load within 3 months if positive