R414-10A-8. Solid Organ Transplantation, Non-Covered Services

  (1) Transplants requiring prior authorization performed without prior authorization. (Refer to the Section I: General Information Provider Manual for request for retroactive authorization for emergency transplant services.)

  (2) Transplant for patients who did not qualify for Medicaid benefits at the time of transplantation. (Retroactive Medicaid qualification may be an exception.)

  (3) Transplants which are experimental or investigational in nature.

  (4) Transplant of beta cells or other pancreas cells not part of a pancreatic organ transplantation.

  (5) Transplant of cells or tissues into the coronary arteries, myocardium, central nervous system, or spinal cord.

  (6) "Bridge-to-transplant" devices for heart transplant:

  (a) Temporary or implanted ventricular assist devices with the exception of intra-aortic balloon assist devices;

  (b) Temporary or implanted biventricular assist devices; or

  (c) Temporary or implanted mechanical heart.

  (7) Transplants to patients with:

  (a) Malignant neoplasm with a high risk for reoccurrence and non-curable malignancy (excluding localized skin cancer).

  (b) Chronic illness with one year or less life expectancy.

  (c) Limited, irreversible rehabilitation potential.

  (8) All other conditions not specifically listed as covered in the rule.