ModifiedmhnPolicy CP.MP.247

Transplant Service Documentation Requirements (PDF)

Defines required clinical documentation for transplant evaluation, listing, post-transplant follow-up visits, and continuity-of-care listing authorizations for solid organ and stem cell/bone marrow transplants for health plans affiliated with Centene Corporation. Specifies timing windows for required documentation and when separate authorizations are required.

Policy Summary

Payermhn

PolicyTransplant Service Documentation Requirements (PDF)

Policy CodePolicy CP.MP.247

Change TypeMultiple revisions (timing, documentation, scope)

Effective Date

Next Review Date

Key ActionProviders must submit the appropriate prior authorization form for transplant evaluation, listing, post-transplant follow-up visits, or continuity-of-care listing authorizations.

SourceLink

POLICY UPDATE CHANGES

Adjusted time requirement to reflect 12 months for kidney transplants and 6 months for other transplants in I.B.3., 4., and 11.

Added requirements for post-transplant follow up visits.

Clarified policy applies to transplant evaluation and listing requests and noted transplant admissions require separate authorization.

Updated various criteria wording (provider vs physician), removed c-peptide from pancreas criteria, added documentation of failed TPN for intestine/multivisceral, and updated infectious testing wording (e.g., RPR).

Updated note that 'transplant evaluations are effective for 12 months' and authorization duration changed from prior 6 months.

Added transplant consultation to Criteria I and updated verbiage across criteria for clarity; no removal of coverage positions.

Standard authorization effective period

6 monthsRecency requirement for non-kidney transplants

12Key required documentation items (approx.)

Coverage Summary

Defines required clinical documentation for transplant evaluation, listing, post‑transplant follow‑up visits, and continuity‑of‑care listing authorizations for solid organ and stem cell/bone marrow transplants for health plans affiliated with Centene Corporation. Applies to both evaluation/consultation and initial or subsequent listing requests and specifies that transplant admissions require a separate prior authorization. References applicable UNOS/OPTN guidance and Centers for Medicare & Medicaid Services National Coverage Determinations (NCDs) for Medicare applicability.

Medical-Necessity Criteria

I. Transplant evaluation or consultation requests (stem cell or solid organ)

Requests are medically necessary when ALL of the following clinical documentation is included:

ALL of the following

Complete history and physical
- Complete history includes history of present illness, list of all current medications, past medical history, pertinent family history and social history, and a complete review of systems
- Physical examination includes height, weight and body mass index (BMI)

I.B. Initial and subsequent transplant listing requests (autologous stem cell, allogeneic stem cell, or solid organ)

Authorization/listing requests are medically necessary when ALL of the following clinical documentation is included:

Complete history and physical timing and content: 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 6 months for other transplant requests, including history of present illness, list of all current medications, past medical history, pertinent family and social history, complete review of systems, and physical examination including height, weight and BMI.H&P: kidney within 12 months; other transplants within 6 months

Laboratory timing: Complete chemistry panel, liver function tests, and complete blood count within 12 months for kidney transplants or within six months for other transplants.kidney: within 12 months; others: within 6 months

Organ-specific testing, imaging, and documentation

I.C. Post-transplant follow-up office visits

Post-transplant follow-up office visits are medically necessary when ALL of the following are provided:

Appropriate prior authorization form

Discharge summary or history and physical from the inpatient hospital stay for the transplant admission

I.D. Continuity of care listing authorizations

Continuity of care listing authorizations are medically necessary when ALL of the following are provided:

Documentation of previous insurer coverage (e.g., previously covered by state Medicaid fee for service)

Documentation of authorization for transplant listings by previous insurer

Copy of UNOS listing for solid organ transplants

II. Additional medically necessary authorizations for multiple facilities or additional evaluations

Authorizations for transplant services at multiple facilities for a single member/enrollee or requests for additional evaluations following transplant listing or after evaluation approval are considered medically necessary when ANY of the following apply:

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 & Requirements

Prior Authorization

Submit appropriate prior authorization form

The appropriate prior authorization form must be submitted for any transplant-related request so the request can be evaluated against policy criteria.

Transplant evaluation requests
Transplant listing (initial and subsequent) requests
Post‑transplant follow‑up office visits
Continuity‑of‑care listing authorizations

Documentation Required

Include required clinical documentation with requests

Include all required clinical documentation with evaluation, listing, post‑transplant follow‑up, or continuity requests to support medical necessity and listing decisions.

Referenced Coding

Referenced coding (informational)CPT

No codes listed

Background & Context

Pre‑transplant evaluations identify conditions that can affect transplant success and include diagnostic tests and consultations necessary to assess candidacy. The policy applies to both solid organ and stem cell/bone marrow transplant evaluation and listing requests. Transplant inpatient admission requests are noted to require a separate authorization. The policy references UNOS/OPTN guidance, CMS National Coverage Determinations, and specialty guidance and standards when outlining the required documentation and timing windows for evaluations and listings.

Definitions

Revision History

11/22timing change (revision)

New policy created and initial revision notes: adjusted time requirement to reflect 12 months for kidney transplants and 6 months for other transplants in I.B.3., I.B.4., and I.B.11.; criteria I.B.2 and I.B.3 wording changed from 'physician' to 'provider'; multiple wording updates including removal of c‑peptide from pancreas criteria and addition of documentation of failed TPN for intestine/multivisceral.

12/22timing change (approval)

Approval reiterating adjusted time requirement (12 months for kidney, 6 months for other transplants) and adding 'with updated clinical documentation' to the note after I.B.11.

11/23annual review / wording updates

Policy Summary

Payermhn

PolicyTransplant Service Documentation Requirements (PDF)

Policy CodePolicy CP.MP.247

Change TypeMultiple revisions (timing, documentation, scope)

Effective Date

Next Review Date

Key ActionProviders must submit the appropriate prior authorization form for transplant evaluation, listing, post-transplant follow-up visits, or continuity-of-care listing authorizations.

SourceLink

On This Page

Liver: INR, MELD or PELD score, hepatitis serologies, imaging studies (MRI, CT, ultrasound), and liver biopsy as indicated

Kidney: GFR or creatinine clearance if not on dialysis

Heart: echocardiogram, right heart catheterization results including pulmonary vascular resistance (PVR), NYHA Class and peak VO2 results

Lung: pulmonary function tests, imaging (chest x-rays and/or CT scans), and six-minute walk test

Pancreas: history of insulin treatment

Intestine/multivisceral: documentation of failed total parenteral nutrition (TPN)

Stem cell: most recent bone marrow biopsy as indicated, most recent ECOG score or Karnofsky score, lumbar puncture if clinically indicated (e.g., acute lymphoblastic leukemia), and documentation of donor identification for allogeneic transplants

Infectious disease screening

Dental and routine screenings: Annual dental evaluation and clearance (transplant clearance from DDS or panoramic dental x-ray with clearance from MD); routine health screening exams per standards of care (e.g., breast, cervical, and/or colon cancer screening); appropriate comorbidity testing/clearance; cardiology testing/clearance including echocardiogram and EKG if indicated; serum or urine drug screen within 90 days of request.drug screen within 90 days
Serologies and testing: CMV and VZV within one year unless baseline IgG antibody positive; EBV within one year unless baseline IgG antibody positive; Toxoplasma titer for heart transplant recipients; results of annual PPD, T-Spot, or QuantiFERON for all solid organ transplants unless previously positive; Hepatitis B testing within one year unless baseline surface antibody positive (if baseline positive, viral load required within 3 months); Hepatitis C testing within one year unless baseline results are positive (if baseline positive, viral load required within 3 months); Rapid plasma reagin (RPR) within one year; HIV within one year unless baseline results are positive (if baseline positive, CD4 count and viral load required within 3 months).serologies within 1 year (exceptions noted)

Other required documentation: Detailed psychosocial evaluation and clearance within 12 months for kidney transplants and within 6 months for other transplants.psychosocial: kidney within 12 months; others within 6 months

Letter of medical necessity from a transplant service provider with signature
Complete history and physical within required timeframe (see timing rules)
Complete chemistry panel, liver function tests, and complete blood count per timing windows
Organ‑specific testing, imaging, and documentation (e.g., INR/MELD for liver, GFR for kidney, echo/right heart cath for heart, PFTs and six‑minute walk for lung, insulin history for pancreas, failed TPN documentation for intestine/multivisceral, bone marrow biopsy/ECOG/Karnofsky and donor ID for stem cell)
Infectious disease screening per policy (CMV, VZV, EBV, toxoplasma for heart, PPD/T‑Spot/QuantiFERON, Hepatitis B and C, RPR, HIV with specified follow‑up if baseline positive)
Serum or urine drug screen results within 90 days
Annual dental evaluation and clearance (DDS transplant clearance or panoramic dental x‑ray with MD clearance)
Detailed psychosocial evaluation and clearance (timing per transplant type)
Donor documentation for allogeneic stem cell transplants

Documentation Required

Maintain timing of tests and clearance

Maintain required recency of tests, clearances, and evaluations so documentation meets policy timing windows for evaluation, listing, or continuity requests.

Complete history and physical: within 12 months for kidney transplant requests; within 6 months for other transplant requests
Chemistry panel, LFTs, CBC: within 12 months for kidney transplants; within 6 months for other transplants
Serum or urine drug screen: within 90 days of request
Infectious disease serologies (CMV, VZV, EBV, Hepatitis B and C, RPR, HIV) within one year unless baseline antibody/positive results noted (see exceptions requiring viral load or CD4/viral load within 3 months when baseline positive)
Psychosocial evaluation and clearance: within 12 months for kidney transplants; within 6 months for other transplants
Approved evaluation requests are effective for 12 months (see auth lapse guidance)

Documentation Required

Provide inpatient discharge documentation for post-transplant follow-up authorization

For post‑transplant follow‑up office visit authorizations, include documentation from the inpatient transplant admission to confirm the recent transplant event and support follow‑up care.

Discharge summary OR history and physical from the inpatient transplant admission

Prior Authorization

Separate authorization for transplant admissions

Transplant inpatient admissions require a separate prior authorization distinct from evaluation or listing authorizations; admission authorizations are not covered by evaluation/listing approvals.

Denial Risk

Auth lapse after 12 months

Approved transplant evaluation and listing requests are effective for 12 months. If more than 12 months elapse, the prior authorization may lapse and the request can be denied without updated documentation.

A new authorization with updated clinical documentation is required after 12 months

Documentation Required

Medical director review for sickle cell anemia and beta thalassemia

Evaluation requests for sickle cell anemia and beta thalassemia must be referred for medical director review to assess relevant symptoms and medical history before authorization.

Annual review with minor rewording and criteria clarifications: provider terminology, documentation additions, removal of c‑peptide, addition of failed TPN documentation, and updated infectious testing language (rapid plasma reagin).

10/24annual review (clarification)

Annual review and background updates; later clarified description that policy applies to transplant evaluation and listing requests and noted transplant admissions require separate authorization (later captured in 02/25 revision).

02/25clarification (revision/approval)

Clarified that the policy applies to transplant evaluation and listing requests and added note that transplant admissions require separate authorization.

03/25added material content (revision/approval)

Added requirements for post-transplant follow-up office visits and an accompanying note regarding authorization requirements for other requests.

04/26 (Approval 05/26)timing change (revision & approval)Latest

Updated note: transplant evaluations are effective for 12 months (changed from prior 6 months); authorization duration changed to 12 months and a new authorization with updated clinical documentation is required after 12 months.