CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Major Organ Transplant Services Coverage Criteria

Defines coverage, authorization, and limitations for major organ transplant services (living and deceased donor) for Neighborhood Health Plan of Rhode Island members in specified Medicaid benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMajor Organ Transplant Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and ensure the transplant is ordered by a plan physician before providing transplant services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yrliving donor harvesting care duration

requiredprior authorization

face & handexperimental exclusions

coveredpost-transplant meds

Coverage Criteria for Major Organ Transplant Services

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Benefit package and ordering: Member is enrolled in an included benefit package (Rhody Health Partners, Rhody Health Options Phase One, RIte Care, Children with Special Health Care Needs, or Substitute Care) and the transplant is ordered by a plan physician.

See chunks 0 and 1 for benefit package listing and ordering requirement.

Transplant types covered: Major organ transplants including heart, lung, kidney, kidney-pancreas (for members with Type 1 Diabetes), liver, and bone marrow/stem cell are covered; this summary does not include bone and tissue transplants.

Chunk 0 lists included organs and excludes bone and tissue transplants.

Donor services for living donors: When the recipient is a Neighborhood member, health care services associated with living donor organ harvesting are covered and billed under the recipient's claim; care related to harvesting is covered for up to 1 year per CMS guidelines.1 year

Chunk 0 describes donor coverage and CMS guideline duration; chunk 3 notes possible Medicaid assistance for donor lodging/food.

Site of care: Episodes of care across inpatient (POS 21) and outpatient (POS 22) settings are included.

Chunk 2 enumerates POS 21 and POS 22.

Authorization: Prior authorization is required before transplant services are provided.

Chunk 1 states authorization requirement and that services must be ordered by a plan physician.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Authorization is required for transplant services. Prior authorization must be obtained before scheduling or performing transplant procedures to ensure coverage.

Applies to major organ transplants (heart, lung, kidney, kidney-pancreas for Type 1 diabetes, liver, bone marrow, stem cell).
Applies to members in Rhody Health Partners, Rhody Health Options Phase One, Rite Care, Children with Special Health Care Needs, and Substitute Care.

Denial Risk

Order and Authorization

Transplant services must be ordered by a plan physician and require authorization prior to the service. Services not ordered by a plan physician or performed without required authorization may be denied.

Order must come from a Neighborhood plan physician.
Failure to obtain required authorization may result in claim denial.

Denial Risk

Authorization Requirement

Failure to obtain required authorization may result in denial of coverage when transplant services are not ordered by a plan physician or authorization is not in place prior to the service.

Ensure authorization is active and documented before the transplant-related admission or procedure.
Donor services for live-donor transplants follow CMS guidelines and billing requirements—confirm authorization processes for associated donor care.

Step Therapy

No step therapy requirements specified for transplant services in this policy section.

Step therapy does not apply to the authorization process for transplant services as described.
Refer to benefit-specific summaries for related medications (e.g., anti-rejection drugs) which are covered while the recipient is an active member.

Background

Human organ transplant replaces a damaged or failing organ with a functioning organ from a living or deceased donor. The policy scope includes major organ transplants such as heart, lung, kidney, kidney-pancreas (for Type 1 diabetes), liver, and bone marrow/stem cell transplantation, while bone and tissue transplants fall outside this benefit summary. Episodes of care may occur across inpatient (POS 21) and outpatient (POS 22) settings. The policy also addresses donor-related care: for living donors where the recipient is a Neighborhood member, harvesting-related health care services are covered and billed under the recipient's claim (with certain donor costs potentially covered by Medical Assistance for fee-for-service Medicaid), and transplant recipients' anti-rejection medications are covered while they remain active members under applicable benefit plans.

Definitions

Human organ transplant — definition and donor types

DefinitionSurgical removal of a whole or partial organ from one body and transplanting it to another to replace a damaged or failing organ; donors may be living or deceased.

Included organ typesHeart; lung; kidney; kidney–pancreas (for Type 1 Diabetes only); liver; bone marrow and stem cell.

Donor typesLiving donors and deceased donors.

Living donor billing and durationWhen recipient is a Neighborhood member, donor harvesting-related health care services are billed under the recipient's claim and covered for up to one (1) year per CMS guidelines.

Evaluation and Pre-Authorization Requirements

Documentation Required

Authorization and ordering; no extra pre-approval workup specified

Transplant services require prior authorization and must be ordered by a plan physician; the document does not specify any additional pre-approval clinical workup steps.

Ensure the ordering provider is a Neighborhood plan physician.
Submit prior authorization before the transplant service occurs.

Post-Transplant Coverage for Recipients and Donors

Anti-rejection medications — Recipient's anti-rejection medications are covered while recipient is active member with specified plans

Coverage ruleTransplant recipient's anti-rejection medications are covered while the recipient is an active member under RIte Care, Substitute Care, Children with Special Health Care Needs (CSN), or Rhody Health Partners (RHP).

Applicable benefit plansRIte Care; Substitute Care; Children with Special Health Care Needs (CSN); Rhody Health Partners (RHP).

ScopeCovers post-transplant immunosuppressive (anti-rejection) medications for eligible members while membership is active.

Living donor harvesting-related care — Covered for up to one year and billed under recipient's claim

Coverage for living donor harvesting careNeighborhood covers the donor's health care services associated with harvesting when the recipient is a Neighborhood member.

Duration limitCare related to harvesting of an organ is covered for up to one (1) year per CMS guidelines.

Billing practicePer CMS guidelines, the donor's services are billed under the recipient's claim(s) from the hospital performing the transplant.