OAR 410-124-0060
Criteria and Contraindications for Heart Transplants
(1)
Prior authorization for a heart transplant will only be approved for a client in whom irreversible heart disease has advanced to the point where conventional therapy offers no prospect for prolonged survival, there is no reasonable alternative medical or surgical therapy and the client’s five (5) year survival rate, subsequent to the transplant, is at least 20 percent as supported by medical literature.(2)
A client considered for a heart transplant must have a poor prognosis (i.e., less than a 50% chance of survival for 18 months without a transplant) as a result of poor cardiac functional status or cardio/pulmonary functional status.(3)
All alternative medically accepted treatments that have a one year survival rate comparable to that of heart transplantation must have been tried or considered.(4)
Requests for transplant services for children suffering from early congenital heart disease may be approved before attempting alternative treatments if medical evidence suggests an early date of transplant is likely to improve the outcome.(5)
A client with one or more of the following contraindications is ineligible for heart transplant services:(a)
Untreatable systemic vasculitis;(b)
Incurable malignancy;(c)
Diabetes with end-organ damage;(d)
Active infection which will interfere with the client’s recovery;(e)
Refractory bone marrow insufficiency;(f)
Irreversible renal disease;(g)
Irreversible hepatic disease;(h)
HIV positive test results.(6)
The following may be considered contraindications to the extent that the evaluating transplant center and/or the specialist who completed the comprehensive evaluation of the client believe the following condition(s) may interfere significantly with the recovery process:(a)
Hyperlipoproteinemia;(b)
Curable malignancy;(c)
Significant cerebrovascular or peripheral vascular disease;(d)
Unresolved or continuing thromboembolic disease or pulmonary infarction;(e)
Irreversible pulmonary hypertension;(f)
Serious psychological disorders;(g)
Drug or alcohol abuse.(7)
The Division of Medical Assistance Programs (Division) will only prior authorize and reimburse for heart transplants if:(a)
All Division criteria are met; and(b)
Both the transplant center’s and the specialist’s evaluations recommend that the transplant be authorized; and(c)
The ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on the same currently funded line on the Prioritized List of Health Services adopted under OAR 410-141-0520.
Source:
Rule 410-124-0060 — Criteria and Contraindications for Heart Transplants, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-124-0060.