Transplant Service Documentation Requirements
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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.
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.
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.
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)
- 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 positivewithin 1 year
- 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
- 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
Provider Actions & Authorization Requirements
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.
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
- 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
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
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.
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
Coding
| 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
Clarified in description that the policy applies to transplant evaluation and listing requests. (is_material: false)
Added that transplant admissions require separate authorization. (is_material: true)
Annual review updates to description, background, and references with no impact on criteria noted (02/24 and 10/24). (is_material: false)
Annual review updates to description, background, and references with no impact on criteria noted (02/24 and 10/24). (is_material: false)
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