Prior authorization required for evaluation, listing, and post‑transplant follow‑up

Prior authorization is required for transplant evaluation requests, transplant listing requests, and post‑transplant follow‑up office visits; inpatient transplant admissions require a separate prior authorization.

• Approved transplant evaluation authorizations are effective for six months.
• Approved transplant listing authorizations are effective for 12 months; after 12 months a new authorization with updated documentation is required.
• Inpatient transplant admissions are not covered under evaluation/listing authorizations and must be authorized separately.

Prior authorization must document medical necessity consistent with plan coverage

Authorization requests must include documentation showing the transplant service meets the Health Plan's medical necessity criteria and is consistent with applicable guidance and NCDs/LCDs; providers should verify Medicare/Medicaid‑specific coverage when applicable.

• Authorization requires submission of the specified clinical documentation listed in the policy (history/physical, labs, organ‑specific testing, psychosocial evaluation, etc.).
• Documentation must align with referenced guidelines (UNOS/OPTN, KDIGO, FACT, CMS) and applicable legal/regulatory requirements.

Include prior authorization form and required documentation or risk denial

Requests for transplant evaluation, listing, post‑transplant follow‑up, or continuity‑of‑care authorizations must include the specified prior authorization form and required clinical documentation; failure to include required forms or documentation may result in denial.

• Include the Health Plan’s prior authorization form with every request.
• Lack of required documentation or an appropriate prior authorization form may result in denial of the request.

Coverage terms, exclusions, and legal conflicts may trigger denial

Coverage decisions and benefit administration are subject to all terms, conditions, exclusions, and limitations of the member’s coverage documents; conflicts with state Medicaid/Medicare rules or plan documents may affect coverage and could trigger denial.

• Verify member benefits and any state Medicaid/Medicare requirements; coverage may vary by contract and state law.
• Discrepancies between this policy and coverage documents or legal requirements are resolved in favor of applicable law or plan documents.

Required documentation: evaluation, listing, post‑transplant follow‑up, and continuity of care

Submit the specified clinical documentation for evaluation, listing, post‑transplant follow‑up, and continuity of care authorizations, including history & physical, medication list, basic labs, organ‑specific testing, infectious disease screening, psychosocial evaluation, dental clearance, and prior insurer/UNOS documentation for continuity of care.

• For transplant evaluation: appropriate prior authorization form and a routine complete history and physical within one year (HPI, med list, past medical/family/social history, ROS, physical exam with height, weight, BMI).
• For initial/subsequent listing: prior authorization form; letter of medical necessity signed by transplant service provider; H&P performed by transplant service provider within 12 months for kidney or 6 months for other transplants; basic labs within those timeframes; organ‑specific testing/imaging as listed; annual dental evaluation/clearance; routine health screenings (not required for autologous stem cell transplant); comorbidity testing/clearance; drug screen within 90 days; infectious disease screening within one year as applicable; detailed psychosocial evaluation within 12 months for kidney and 6 months for other transplants.
• For continuity of care: documentation of prior insurer coverage, prior authorization evidence from previous insurer, and a copy of the UNOS listing.

Post‑transplant follow‑up: include prior authorization form and discharge summary/H&P

For post‑transplant follow‑up office visit prior authorization requests, include the appropriate prior authorization form plus the inpatient transplant admission discharge summary or the inpatient history & physical from the transplant admission.

• If requesting authorization for services unrelated to post‑transplant follow‑up office visits, verify separate authorization requirements via the health plan's prior authorization tool.

Submit documentation that supports medical necessity per plan and law

Providers must submit documentation demonstrating medical necessity consistent with the Health Plan’s coverage documents, applicable laws/regulations, and generally accepted standards of medical practice; documentation should reference relevant guidelines as needed.

• Documentation must support that the requested transplant service meets the plan’s medical necessity criteria and align with referenced guidance (UNOS, OPTN, KDIGO, FACT, CMS).
• Providers are responsible for complying with applicable legal and regulatory requirements when submitting documentation.

Requests must include all specified documentation and prior authorization form

Prior authorization requests must include the specific documentation listed in this policy (H&P, labs, organ‑specific testing, infectious disease screening, psychosocial evaluation, dental clearance, drug screen, letter of medical necessity, prior authorization form); missing required items may result in denial.

• Requests for evaluation, listing, post‑transplant follow‑up, or continuity of care must include the specified documentation and prior authorization form.
• Approved evaluation requests are effective for six months; approved listing requests are effective for 12 months—transplant admissions need separate authorization.

Evaluation must include H&P, labs, organ‑specific testing, infectious disease screening, psychosocial, and dental clearance

A complete pre‑transplant evaluation must include a detailed history and physical, basic laboratory testing, organ‑specific testing/imaging as listed, infectious disease screening as applicable, psychosocial evaluation, and dental clearance when required.

• History & physical with HPI, medication list, past medical/family/social history, ROS, and physical exam including height, weight and BMI.
• Basic labs (CBC, chemistry/LFTs) within applicable timeframes (kidney 12 months; other organs six months).
• Infectious disease screening (CMV, VZV, EBV, Hepatitis B/C, HIV, RPR, TB testing) within one year as applicable.
• Organ‑specific testing per organ (e.g., MELD/INR for liver; GFR for kidney; echo/right heart cath for heart; PFTs and 6‑minute walk for lung).
• Detailed psychosocial evaluation within 12 months for kidney and six months for other transplants; annual dental evaluation and clearance.

Center and program requirements referenced; specific accreditation/volume criteria not listed here

Policy references transplant service providers and transplant programs and notes applicable accreditation and regulatory standards (FACT, OPTN/UNOS, CMS) but does not list specific center accreditation or volume requirements in this excerpt.