CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Organ Transplant Services

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Establishes District Medicaid coverage, reimbursement, prior authorization, clinical eligibility, provider participation, and exclusion standards for liver, heart, lung, kidney, allogeneic stem cell, and autologous hematopoietic stem cell transplantation.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyOrgan Transplant Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 23, 2015

Next Review DateN/A

Key ActionEvery transplantation procedure must be prior authorized by the Department of Health Care Finance or its designee before the service is provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Eligible transplant types

100%Procedures requiring prior authorization

≤20Kidney GFR threshold

13Lung contraindication categories

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CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Organ Transplant Services

Customize your policy alerts

Sign up for all District of Columbia Department of Health Care Finance policy alerts

Know when District of Columbia Department of Health Care Finance releases new policies or updates existing guidance.

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Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyOrgan Transplant Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 23, 2015

Next Review DateN/A

Key ActionEvery transplantation procedure must be prior authorized by the Department of Health Care Finance or its designee before the service is provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Eligible transplant types

100%Procedures requiring prior authorization

≤20Kidney GFR threshold

13Lung contraindication categories

General malignancy-free interval

Covered Transplant Services

General transplant eligibility

Transplantation is eligible when all of the following general criteria are met.

General transplant medical necessity: The recipient is diagnosed with a condition for which transplantation is recommended as medically necessary for survival; is reasonably expected to have sufficient mental capacity and awareness to undergo the mental and physical rigors of post-transplant rehabilitation and adhere to the long-term medical regimen; is reasonably expected to recover sufficiently to resume physical and social activities of daily living; alternative medical and surgical therapies expected to yield short- and long-term survival have been tried or considered and found insufficient to prevent progressive deterioration and death; and has no other system disease, major organ disease, or condition likely to complicate, limit, or preclude expected recuperation and rehabilitation.

Liver transplantation

Covered for liver transplantation when the recipient has a qualifying diagnosis or clinical condition.

Qualifying liver conditions: Cirrhosis with hepatic decompensation, primary biliary cirrhosis, primary sclerosing cholangitis, fulminant hepatic failure, or cirrhosis with hepatocellular carcinoma.

The listed conditions are not exhaustive.

Heart transplantation

Covered for heart transplantation when the recipient has a qualifying diagnosis or clinical condition.

Heart transplant condition: The recipient has end-stage heart disease.

Lung transplantation

Covered for lung transplantation when both the disease-severity requirement and a listed diagnosis are present.

Qualifying lung transplant condition

Disease severity: The recipient has chronic, irreversible, progressively disabling, end-stage lung disease that is failing medical therapy or for which no effective medical therapy exists.
Qualifying lung diagnoses: The recipient has at least one of the following: alpha-1 antitrypsin deficiency; bilateral bronchiectasis; bronchiolitis obliterans; bronchopulmonary dysplasia; chronic obstructive pulmonary disease; cystic fibrosis; Eisenmenger's syndrome; emphysema; idiopathic pulmonary fibrosis; lymphangiomyomatosis; primary pulmonary hypertension; pulmonary fibrosis; pulmonary hypertension due to cardiac disease; recurrent pulmonary embolism; sarcoidosis; or scleroderma.

Kidney transplantation

Covered for kidney transplantation when the recipient meets at least one qualifying renal criterion and the applicable documentation requirement.

Qualifying kidney condition: The recipient has stage 4 or stage 5 renal disease on chronic dialysis with GFR less than or equal to 20 mL/min/1.73 m², or has end-stage renal disease.GFR ≤20 mL/min/1.73 m² when paired with chronic dialysis

Documented kidney eligibility: The recipient is receiving chronic dialysis and has GFR less than or equal to 20 mL/min/1.73 m², or has stage IV chronic kidney disease with written UNOS documentation of official ACTIVE waitlist status and clinical documentation that renal failure is rapidly progressing.

Allogeneic stem cell transplantation

Covered for allogeneic stem cell transplantation when the recipient has a qualifying hematologic diagnosis and is not excluded by the policy.

Allogeneic transplant criteria

Qualifying hematologic diagnoses: Acute myelogenous leukemia, acute lymphocytic leukemia, myelodysplastic syndrome, chronic myelogenous leukemia, non-Hodgkin's lymphoma, or chronic lymphocytic leukemia.
The listed conditions are not exhaustive.
Exclusion: The recipient is not diagnosed with multiple myeloma.

Autologous hematopoietic stem cell transplantation

Covered for autologous hematopoietic stem cell transplantation when the recipient has a qualifying diagnosis and none of the listed exclusions.

Autologous transplant criteria

Qualifying diagnoses: Acute myelogenous leukemia, non-Hodgkin's lymphoma, Hodgkin's lymphoma, multiple myeloma, or recurrent neuroblastoma with localized brain recurrence after surgical resection.
The listed conditions are not exhaustive.
Exclusions absent: The recipient does not have acute leukemia not in remission, chronic granulocytic leukemia, a solid tumor other than neuroblastoma, or tandem transplantation for multiple myeloma.

Liver transplantation is not eligible for D.C. Medicaid beneficiaries with hepatocellular carcinoma initially staged outside the Milan Criteria or subsequently downstaged to within the Milan Criteria through locoregional therapy.

Kidney transplant reimbursement excludes recipients with reversible renal failure; active infection, including hepatitis, cytomegalovirus, Epstein-Barr virus, or HIV infection; an anatomic anomaly that precludes transplantation; cancer other than localized non-melanoma skin cancer; advanced or uncorrectable coronary artery disease or congestive heart failure; advanced or severe pulmonary disease; cerebrovascular disease; severe peripheral vascular disease or claudication; or other organ-system failure.

Allogeneic stem cell transplantation is not covered for recipients diagnosed with multiple myeloma.

Autologous hematopoietic stem cell transplantation is excluded for acute leukemia not in remission, chronic granulocytic leukemia, solid tumors other than neuroblastoma, and tandem transplantation for recipients with multiple myeloma.

Clinical Thresholds and Contraindication Values

Kidney Transplant GFR

Kidney transplant GFR thresholdLess than or equal to 20 mL/min/1.73 m²

Qualifying renal conditionStage 4 or stage 5 renal disease on chronic dialysis with a GFR less than or equal to 20 mL/min/1.73 m²

Alternative documentation pathwayStage IV chronic kidney disease with official ACTIVE UNOS wait-list status and rapidly progressing renal failure

Lung Transplant BMI Contraindication

BMI thresholdExceeding 30 kg/m2

Clinical classificationSevere obesity

Application

Authorization, Documentation, and Exclusion Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required before service. Every transplantation procedure must be prior authorized by the District of Columbia Department of Health Care Finance or its designee before the service is provided.

Applies to liver, heart, lung, kidney, allogeneic stem cell, and autologous hematopoietic stem cell transplantation.
Services must comply with the clinical standards established under the State Plan for Medical Assistance and 42 C.F.R. § 441.35.

Documentation Required

Transplant Center Qualification

Confirm that the transplant program or center satisfies all participation requirements before submitting the claim. The center must be qualified for the specific organ or organs being transplanted.

Located in a Medicare-enrolled hospital.

Policy Scope and Program Context

This policy establishes Medicaid coverage and reimbursement standards for solid-organ transplantation—including liver, heart, lung, and kidney transplantation—and hematopoietic stem cell transplantation for District Medicaid recipients. Coverage depends on medical necessity for survival, inadequate alternative therapies, the recipient’s ability to participate in rehabilitation and adhere to long-term treatment, applicable procedure-specific criteria, and use of a qualified transplant center. The recipient must remain enrolled and eligible in District Medicaid throughout hospitalization and follow-up treatment.

Key Policy Terms

Allogeneic Stem Cell Transplantation

ProcedureThe transplanted stem cells come from a donor

Donor matchingThe donor's tissue type closely matches the recipient's

Transplant typeStem cell transplantation

Autologous Hematopoietic Stem Cell Transplantation

Cell sourceThe recipient's healthy stem cells

CollectionThe healthy stem cells are harvested from the recipient

ProcedureThe harvested cells are transplanted into the recipient

Transplant Candidate Requirements

General candidate criteria

A transplant candidate must meet all general medical-necessity and rehabilitation criteria.

General candidate criteria: The recipient remains enrolled in Medicaid throughout hospitalization and follow-up; transplantation is medically necessary for survival; the recipient has sufficient mental capacity and awareness for rehabilitation and adherence to the long-term regimen; recovery to activities of daily living is reasonably expected; alternative therapies are inadequate; and no major disease or condition is likely to compromise recuperation or rehabilitation.

Kidney candidate criteria

Kidney candidates must meet one of the renal disease pathways and satisfy the specified documentation pathway.

Kidney candidate pathway: The recipient has stage 4 or stage 5 renal disease on chronic dialysis with GFR less than or equal to 20 mL/min/1.73 m²; has end-stage renal disease; or has stage IV chronic kidney disease with written documentation of official ACTIVE UNOS waitlist status and clinical documentation that renal failure is rapidly progressing.GFR ≤20 mL/min/1.73 m²

Transplant Contraindications

General contraindications include malignancy within the last 2 years, except cutaneous squamous and basal cell tumors; a 5-year disease-free interval is generally prudent. Other contraindications include untreatable advanced dysfunction of another major organ system, non-curable chronic extrapulmonary infection, significant chest wall or spinal deformity, documented nonadherence, untreatable psychiatric or psychological conditions affecting compliance, unreliable social support, active substance addiction or addiction within the prior 6 months, critical or unstable illness, poor rehabilitation potential, highly resistant or virulent infection colonization, severe obesity with BMI exceeding 30 kg/m², and mechanical ventilation.

Recipient Evaluation

Documentation Required

Complete the transplant evaluation

Evaluate and document the recipient’s diagnosis and medical necessity for survival, rehabilitation capacity, adherence to long-term treatment, expected recovery to activities of daily living, adequacy of alternative treatments, and comorbid conditions that could compromise recovery.

Document sufficient mental capacity and awareness for post-transplant rehabilitation and adherence to the long-term medical regimen.
Document that alternative medical and surgical therapies were tried or considered and found insufficient.
For kidney candidates, document the applicable dialysis/GFR or stage IV chronic kidney disease pathway.

Transplant Program Qualifications

Documentation Required

Confirm center requirements

Use a transplant program or center that is located in a Medicare-enrolled hospital, certified by and a member in good standing of OPTN for the specific organ or organs being transplanted, and enrolled in the D.C. Medicaid program.

A District center must maintain the applicable Certificate of Need issued by SHPDA.
An out-of-District center must maintain the transplant program or center requirements of the applicable state or jurisdiction.

Hospitalization and Follow-Up Coverage

Post-Transplant Coverage

Covered servicesTransplantation services and related hospitalization and follow-up treatment

Coverage periodThroughout the period of hospitalization and follow-up treatment

Eligibility conditionThe recipient must remain enrolled and eligible in the District Medicaid program

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyOrgan Transplant Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 23, 2015

Next Review DateN/A

Key ActionEvery transplantation procedure must be prior authorized by the Department of Health Care Finance or its designee before the service is provided.

SourceLink

On This Page

Listed as a contraindication for lung transplantation

Recent Substance Addiction

TimingActive or within the last six months

Substances identifiedAlcohol, tobacco, or narcotics

Clinical applicationListed as a contraindication for lung transplantation

Recent Malignancy

Recent malignancy periodWithin the last two years

ExceptionCutaneous squamous and basal cell tumors are excepted

Generally prudent intervalA five-year disease-free interval

Certified by, and a member in good standing of, the Organ Procurement and Transplantation Network (OPTN) for the specific organ or organs being transplanted, consistent with 42 C.F.R. §§ 482.72, 482.74, and 482.76.

If located in the District, maintains the applicable Certificate of Need issued by SHPDA under D.C. Official Code § 44-406.

If located outside the District, meets the transplant program or center requirements of the applicable state or jurisdiction.

Enrolled in the D.C. Medicaid program.

Documentation Required

Kidney Eligibility Documentation

Document kidney-transplant eligibility through an accepted clinical pathway. The record must establish the applicable renal-disease diagnosis and include the required supporting documentation.

Chronic dialysis with stage 4 or stage 5 renal disease and GFR ≤ 20 mL/min/1.73 m²; or a diagnosis of End-Stage Renal Disease (ESRD).
For stage IV chronic kidney disease, include written UNOS documentation that the recipient is officially activated on the wait-list as “ACTIVE” and clinical documentation that renal failure is rapidly progressing.
Retain dialysis records, GFR results, renal-disease staging, UNOS activation documentation, and supporting clinical notes.

Documentation Required

General Medical-Necessity Documentation

Submit records supporting medical necessity and the recipient’s ability to benefit from transplantation. Documentation should connect the diagnosis to the need for transplantation and establish readiness for recovery and long-term care.

Diagnosis and physician recommendation that transplantation is medically necessary for the recipient’s survival.
Reasonable expectation that the recipient has sufficient mental capacity and awareness to undergo the mental and physical rigors of post-transplant rehabilitation and adhere to the required long-term medical regimen.
Reasonable expectation of sufficient recovery to resume physical and social activities of daily living.
Alternative medical and surgical therapies expected to provide short- and long-term survival were tried or considered and found insufficient to prevent progressive deterioration and death.
No other system disease, major organ disease, or condition likely to complicate, limit, or preclude expected recuperation and rehabilitation after transplantation.
Include relevant diagnostic reports, treatment history, rehabilitation assessment, adherence history, and other supporting medical records.

Billing Rule

Recipient and Provider Eligibility

Verify eligibility for both the recipient and the rendering transplant provider before services are furnished. Medicaid reimbursement is available only while the recipient remains eligible through hospitalization and follow-up treatment.

Recipient must be currently enrolled in the District’s Medicaid program and remain eligible throughout the hospitalization and follow-up treatment period.
Services must be performed by an eligible transplant program or center.
The transplant center must be enrolled in the D.C. Medicaid program and meet the applicable Medicare hospital, OPTN, licensing or jurisdictional, and District CON requirements.

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Unsupported block type: denial_risk

Denial Risk

Lung Contraindications

Screen and document lung-transplant contraindications before requesting authorization. The following categories may preclude Medicaid reimbursement when they affect transplant candidacy.

Malignancy within the last 2 years, except cutaneous squamous-cell and basal-cell tumors; a 5-year disease-free interval is generally prudent.
Untreatable advanced dysfunction of another major organ system, including coronary artery disease not amenable to percutaneous intervention or bypass grafting or associated with significant left-ventricular impairment.
Non-curable chronic extrapulmonary infection, including chronic active hepatitis B, hepatitis C, or HIV.
Significant chest-wall or spinal deformity.
Documented nonadherence or inability to follow medical therapy or office follow-up.
Untreatable psychiatric or psychological condition preventing cooperation or compliance with medical therapy.
No consistent or reliable social-support system.
Active substance addiction, or addiction within the last 6 months, involving alcohol, tobacco, or narcotics.
Critical or unstable clinical condition, including shock, mechanical ventilation, or extracorporeal membrane oxygenation.
Severely limited functional status with poor rehabilitation potential.
Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria.
Severe obesity with BMI exceeding 30 kg/m².
Mechanical ventilation.

Denial Risk

Kidney Transplant Exclusions

Do not submit kidney-transplant services for reimbursement when the recipient has one or more listed exclusion conditions. Document that these exclusions were assessed and addressed before authorization.

Reversible renal failure.
Active infection, including hepatitis, cytomegalovirus, Epstein-Barr virus, or HIV infection.
Anatomic anomaly that precludes kidney transplantation.
Cancer, except localized non-melanoma skin cancer.
Advanced or uncorrectable coronary artery disease or congestive heart failure.
Advanced or severe pulmonary disease.
Cerebrovascular disease.
Severe peripheral vascular disease or claudication.
Other organ-system failure.

Denial Risk

Stem Cell Transplant Exclusions

Apply the diagnosis-specific exclusions for hematopoietic stem cell transplantation before requesting authorization. The record must identify whether the procedure is allogeneic or autologous and address the applicable exclusion criteria.

Allogeneic transplantation is not reimbursable when the recipient is diagnosed with multiple myeloma.
Autologous transplantation is not reimbursable for acute leukemia not in remission.
Autologous transplantation is not reimbursable for chronic granulocytic leukemia.
Autologous transplantation is not reimbursable for solid tumors other than neuroblastoma.
Autologous tandem transplantation, meaning multiple rounds of hematopoietic stem cell transplantation, is not reimbursable for recipients with multiple myeloma.

Contraindication

DefinitionA specific situation in which a drug, procedure, or surgery is typically not to be used

ReasonBecause it may be harmful to the patient

ScopeMay apply to a drug, procedure, or surgery

Period of Hospitalization

DefinitionThe total period of time that the person is receiving medical services related to the transplantation procedure

MeasurementTotal period of time

Services includedMedical services related to the transplantation procedure

Prior Authorization

DefinitionThe process of obtaining authorization before the beneficiary receives services

Authorizing agencyDepartment of Health Care Finance

TimingAuthorization is obtained before services are provided

Recipient

DefinitionThe Medicaid-enrolled person who is receiving transplantation services

Program statusEnrolled in Medicaid

RolePerson receiving transplantation services