R414-10A-6. Prior Authorization

  (1) Prior authorization (PA) may be required for any transplantation service.

  (a) To determine if PA is required, refer to the Utah Medicaid Coverage and Reimbursement Code Lookup tool.

  (2) The Department's evidence-based criteria may be used, when available, as part of the PA process.

  (3) If PA is required, the request must include documentation that the patient meets the organ specific requirements in this rule.

  (4) The PA request for transplantation services must include:

  (a) A description of condition needing transplantation;

  (b) Transplantation treatment alternatives utilized previous to the transplant request;

  (c) Transplantation treatment alternatives considered and discarded, including rationale for discarding;

  (d) A comprehensive examination, evaluation and recommendation completed by a Board-Certified or Board-Eligible specialist and medical and surgical specialists in the field directly related to the patient's condition, which demonstrates the need for a transplant. The patient must also demonstrate the ability to tolerate the proposed transplant and subsequent treatment regimen;

  (e) A comprehensive psycho-social evaluation of the patient that includes:

  i. motivation for transplant;

  ii. willingness and ability to follow a long-term treatment and follow-up regimen; and

  iii. history of active substance use.

  (f) If the patient is less than 18 years of age, a comprehensive psycho-social evaluation of the patient's parent or guardian that includes:

  i. motivation for transplant;

  ii. willingness and ability to follow a long-term treatment and follow-up regimen; and

  iii. history of active substance use.

  (g) A comprehensive psychiatric evaluation, if the patient has a history of mental illness.

  (h) Documentation of a successfully completed treatment program or abstinence, if the patient has a history of substance use.

  (i) Treatment program success and abstinence are supported by negative drug screens for a minimum of six months, with two negative drug screens in the most recent three months. The timing of the drug screens is in relation to the PA request date.

  (j) If the history of substance use involves drugs other than those listed in this rule under Section R414-10A-2, then the drug screens must include the other substance upon drug testing availability.

  (k) The patient may not be an active substance user as defined under Section R414-10A-2.

  (l) Comprehensive infectious disease evaluation for a patient with a recent or current suspected infectious episode.

  (m) All applicable hospital and clinic records.

  (n) Completed cancer screening tests.

  (o) All relevant laboratory and imaging studies.

  (p) Documentation that the patient meets the eligibility and selection criteria for the transplant facility where the transplant will be performed.

  (q) Any other documentation requested by PA or the Department's physician consultants.

  (5) If incomplete documentation is received by the Department, the patient's case is pended until the requested documentation has been received.

  (6) If a transplant requiring PA is performed without PA, reimbursement may be denied for all services related to the transplant up to the outlier threshold days for the specific type of transplant.

  (7) Refer to the Section I: General Information Provider Manual for retroactive authorization for emergency transplant services.