R414-10A-7. Solid Organ Transplantation, Covered Services and Requirements

  (1) The following solid organ transplant services are covered. Minimum requirements for specific transplant services are shown. As required by 42 CFR 482, Subpart E, each transplant center must also have written selection criteria.

  (2) All patients must be free of active infection. Liver transplants are excepted as noted.

  (3) Liver.

  (a) The patient must:

  (i) have progressive, irreversible liver disease requiring transplant;

  (ii) be free from active infection outside the hepatobiliary system;

  (iii) not have acute, severe hemodynamic compromise at the time of transplantation if this compromises non-hepatic end-organs;

  (iv) be free from significant pulmonary disease;

  (v) be free from any significant cardiovascular disease; and

  (vi) not have stage IV hepatic coma.

  (4) Cornea.

  (a) The patient must be free of other associated disease that may preclude visual improvement with transplant.

  (5) Cardiac.

  (a) The patient must:

  (i) have irreversible and progressive cardiac disease with a life expectancy of one year or less without transplant or progressive pulmonary hypertension without other treatment options; and

  (ii) be free from significant pulmonary disease, except pulmonary hypertension.

  (6) Intestine.

  (a) The patient must:

  (i) have short bowel syndrome or irreversible and progressive small bowel disease requiring daily hyperalimentation without reasonable alternatives;

  (ii) be free from significant pulmonary disease; and

  (iii) be free from significant cardiovascular disease.

  (7) Kidney.

  (a) The patient must:

  (i) have irreversible, progressive end-stage renal disease;

  (ii) not have acute, severe hemodynamic compromise at the time of transplantation if this compromises non-renal end-organs;

  (iii) be free from significant pulmonary disease; and

  (iv) be free from any significant cardiovascular disease.

  (8) Lung.

  (a) The patient must:

  (i) not have acute, severe hemodynamic compromise at the time of the transplantation if this compromises non-pulmonary end-organs;

  (ii) be free from significant cardiovascular disease; and

  (iii) demonstrate abstinence from tobacco use within the last 6 months.

  (9) Pancreas.

  (a) The patient must:

  (i) have type I diabetes mellitus;

  (ii) not have acute, severe hemodynamic compromise at the time of the transplantation if this compromises end-organs;

  (iii) not have active peptic ulcer disease;

  (iv) be free from significant cardiovascular disease; and

  (v) be free from significant pulmonary disease.

  (10) Multi-organ transplants.

  (a) Kidney/pancreas, liver/kidney, cardiac/lung, intestine/liver, and other multi-organ transplants may be considered;

  (i) each case is reviewed individually as to medical necessity and appropriateness; and

  (ii) complete documentation, including justification and outcomes, must be provided.