Fidelis Care transplant documentation Prior Auth

Coverage Criteria

Initial evaluation and listing criteria

Covered when ALL of the following are met

I.A Transplant evaluation requests: For transplant evaluation requests, ALL: appropriate prior authorization form; complete history and physical within one year.

Complete H&P includes HPI, medication list, past medical/family/social history, review of systems, physical exam including height/weight/BMI. Evaluation approvals effective for six months.

I.B Initial/subsequent transplant listing requests: For initial and subsequent autologous stem cell transplants or initial and subsequent allogeneic stem cell or solid organ transplant listing requests, ALL: appropriate prior authorization form; letter of medical necessity signed by transplant service provider; complete history and physical performed by a transplant service provider within 12 months for kidney transplant requests or 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; appropriate testing, imaging, and documentation specific to the requested transplant; annual dental evaluation and clearance; routine health screening exams per standards of care; appropriate comorbidity testing/clearance; cardiology testing/clearance; serum or urine drug screen results within 90 days of request; infectious disease screening per policy list; detailed psychosocial evaluation and clearance within 12 months for kidney transplants and six months for other transplants.

Organ-specific tests: liver (INR, MELD/PELD, hepatitis serologies, MRI/CT/US, biopsy as indicated); kidney (GFR or creatinine clearance if not on dialysis); heart (echo, right heart catheterization including PVR, NYHA class, peak VO2); lung (PFTs, chest x-ray/CT, six-minute walk test); pancreas (history of insulin treatment); intestine/multivisceral (documentation of failed TPN); stem cell (most recent bone marrow biopsy as indicated, most recent ECOG/Karnofsky, lumbar puncture if indicated, donor identification for allogeneic).

Post-transplant follow-up

Covered when ALL of the following are met

I.C Post-transplant follow-up visits: For post-transplant follow up office visits, ALL: appropriate prior authorization form; discharge summary or history and physical from the inpatient hospital stay for the transplant admission.

Other unrelated services require separate authorization via the health plan prior authorization tool.

Multiple facility/additional evaluations

Covered when ANY of the following are met

II Multiple facility or additional evaluations: Authorizations for transplant services at multiple facilities for a single member or requests for additional evaluations following transplant listing or after a prior transplant evaluation approval are medically necessary if ANY: the member has an episode of illness resulting in a change to transplant eligibility status; 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 specialty autotransplant procedures. Specifically, requests for corneal transplant, pancreatic islet cell auto‑transplant after pancreatectomy, and parathyroid auto‑transplant after thyroidectomy are not covered under this document and must be submitted using the Health Plan–specific prior authorization form available on the Health Plan website.

All coverage decisions made under this clinical policy are subject to the terms of the member's coverage documents. Providers and reviewers must consider the member's evidence of coverage, certificate of coverage, policy, or contract, as applicable, since exclusions, limitations, and other plan‑level provisions may affect eligibility or payment.

The procedure, diagnosis, and billing codes referenced in this policy are provided for informational purposes only. Inclusion or exclusion of any codes in this policy does not guarantee coverage. Providers should consult current coding resources and plan guidance prior to claim submission.

Coding and Documentation Timeframes

Referenced code systemsmixed

No codes listed

Documentation time windows — transplant

Kidney transplant documentation windowComplete H&P, chemistry/LFT/CBC, psychosocial evaluation and other listing items must be within 12 months for kidney transplant listing requests.

Other transplants documentation windowComplete H&P, chemistry/LFT/CBC, psychosocial evaluation and other listing items must be within 6 months for non-kidney transplant listing requests.

Evaluation H&P acceptabilityFor transplant evaluation requests a complete history and physical performed by a transplant service provider may be acceptable if within one year of the request.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

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

Evaluation authorizations are effective for six months; approved transplant listings are effective for 12 months and require updated documentation and a new authorization after 12 months.
Requests lacking required clinical documentation (completed prior authorization form, current history & physical, required labs, imaging, and organ‑specific tests) may be denied or returned for additional information.
For post‑transplant follow‑up office visit requests, include the appropriate prior authorization form and the discharge summary or history & physical from the transplant hospitalization.

Documentation Required

Provider Documentation and Compliance

Submit the appropriate prior authorization form and all required clinical documentation with evaluation, listing, and post‑transplant follow‑up requests. Required documentation includes the transplant PA form, complete history & physical within the specified timeframes, relevant laboratory testing, imaging, organ‑specific testing, infectious disease screening, psychosocial evaluation, and any additional items listed in the policy.

Candidate and Organ-specific Criteria

Organ-specific evaluation requirements

Organ- and transplant-type specific documentation required as part of listing requests

Liver-specific: Require international normalized ratio (INR); MELD or PELD score; hepatitis serologies; imaging studies (MRI, CT, ultrasound); and liver biopsy as indicated.

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

Heart-specific: Require echocardiogram; right heart catheterization results including pulmonary vascular resistance (PVR); New York Heart Association (NYHA) class; and peak VO2 results.

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

Contraindications

During the pretransplant assessment the clinical team should identify conditions that would complicate surgery or adversely affect postoperative recovery. Examples include active infections, significant uncontrolled comorbidities (for example advanced cardiovascular, pulmonary, renal, or hepatic disease), and markedly poor functional status. The evaluation should document any findings that increase operative or post‑transplant risk and determine whether those conditions can be optimized prior to listing or transplantation.

For hematopoietic stem cell candidates, the pretransplant workup should also assess disease‑specific factors and organ function that influence transplant tolerance, including cardiac and pulmonary status, infectious risks, and performance status (e.g., ECOG or Karnofsky) as applicable.

Because infection and malignancy are important determinants of post‑transplant outcomes, active or uncontrolled infections and conditions that substantially increase infection risk should be identified and managed before proceeding with transplantation.

Evaluation Requirements

Documentation Required

Include complete H&P, labs, organ‑specific testing, infectious disease screening, and psychosocial evaluation

The comprehensive transplant evaluation must include a complete history and physical, laboratory panels (chemistry, LFTs, CBC), organ‑specific testing and imaging, infectious disease screening, serum/urine drug screen, dental evaluation/clearance, comorbidity and cardiology testing/clearance, and a detailed psychosocial assessment within the specified timeframes.

Complete H&P and required labs: within 12 months for kidney listings or 6 months for other transplant listings (evaluation H&P may be within one year).
Organ‑specific testing per organ as enumerated in policy (liver, kidney, heart, lung, pancreas, intestine, stem cell).
Infectious disease screening and drug screen within 90 days; dental clearance and psychosocial evaluation within required windows.

Note

Review NCDs/LCDs and specialty guidance as part of the evaluation

Providers should review applicable Medicare NCDs/LCDs and specialty guidance (e.g., UNOS/OPTN, UpToDate) as part of the evaluation prior to transplant authorization.

Consult UNOS/OPTN guidance and other specialty resources referenced by the Health Plan as appropriate.

Transplant Center Requirements

Prior Authorization

Submit requests for acceptance into a participating transplant program; inpatient admissions require separate authorization

Requests must be submitted for acceptance into a transplant program at a participating facility; transplant inpatient admissions require a separate prior authorization per plan guidance.

Authorization requests should identify the receiving transplant program and confirm participation with the Health Plan.
Inpatient transplant admissions are not covered under the evaluation/listing authorization and need separate authorization.

Note

Follow FACT and other accreditation standards as applicable

Refer to accreditation and standards such as FACT where applicable (e.g., hematopoietic cellular therapy) when preparing documentation and meeting center requirements.

Ensure center accreditation and standards are consistent with the references and facility participation requirements.
Include documentation that demonstrates adherence to applicable accreditation standards when requested.

Post-Transplant Coverage

Post‑transplant outpatient follow‑up visits

Prior authorization requiredPost-transplant follow-up office visits require an appropriate prior authorization form.

Inpatient documentation requiredSubmission of the discharge summary or history and physical from the inpatient transplant admission is required with the request.

Separate authorization for unrelated servicesAuthorization requirements for services unrelated to post-transplant follow-up office visits must be checked via the health plan's prior authorization tool.

Definitions

Performance status scoring

Performance status scales referencedPerformance status should be assessed using the Eastern Cooperative Oncology Group (ECOG) scale or Karnofsky Performance Status.

Use in stem cell candidacyMost recent ECOG or Karnofsky score is required for stem cell transplant listing requests as part of clinical assessment.

Role in eligibility assessmentFunctional status assessment via these scales is used alongside comorbidities, organ function, and psychosocial status to determine eligibility.

Liver disease severity scoring

Liver severity scoresLiver transplant evaluation requires Model for End Stage Liver Disease (MELD) or Pediatric End Stage Liver Disease (PELD) score.

Related liver testing

Background

The purpose of the pretransplant evaluation is to comprehensively assess a candidate's suitability for transplant and to identify factors that may affect transplant success. This includes reviewing medical comorbidities, infectious disease risk and screening, and functional status, as well as documenting prior exposures and vaccination history. For solid organ candidates, the evaluation focuses on organ‑specific testing and optimization; for stem cell candidates it includes assessment of the underlying disease, organ function, and performance status.

A thorough pretransplant review also examines medication management and social supports required for adherence to complex post‑transplant regimens. Information gathered during the evaluation — including diagnostic testing, consultations, and psychosocial assessment — informs listing decisions and helps identify issues that require intervention prior to transplantation.

The clinical data collected during the evaluation (history and physical, labs, imaging, infectious disease screening, cardiopulmonary testing, psychosocial assessment, etc.) form the basis for medical necessity determinations and for any required prior authorization for evaluation, listing, or post‑transplant follow‑up services.

OpenPayer

Transplant Service Documentation Requirements