OAR 410-124-0080
Criteria and Contraindications for Autologous and Allogeneic Bone Marrow, Autologous and Allogeneic Peripheral Stem Cell and Allogeneic Cord Blood Transplants
(1)
The following criteria will be used to evaluate the prior authorization request for all bone marrow and peripheral stem cell transplants:(a)
Transplantation must be the most effective medical treatment, when compared to other alternatives, in prolonging life expectancy to a reasonable degree;(b)
The client must have a maximum probability of a successful clinical outcome and the expectation of not less than a 20 percent five (5) year survival rate, subsequent to the transplant, as supported by medical literature considering each of the following factors:(A)
The type of transplant (i.e., autologous or allogeneic);(B)
The specific diagnosis of the individual;(C)
The stage of illness (i.e., in remission, not in remission, in second remission);(D)
Satisfactory antigen match between donor and recipient in allogeneic transplants;(c)
All alternative treatments with a one-year survival rate comparable to that of bone marrow transplantation must have been tried or considered.(2)
Allogeneic transplants will be approved for payment only when there is a minimum of 5-out-of-6 antigen match for bone marrow and peripheral stem cell transplants, or 4-out-of-6 match for cord blood transplants, considering the HLA-A, B, and DR loci. Donor search costs up to an amount of $15,000 will be covered only if prior authorized.(3)
Donor leukocyte infusions are covered only when:(a)
An early failure or relapse post allogeneic bone marrow transplant occurs; and(b)
Peripheral stem cells are from the original donor.(4)
The following are contraindications for autologous and allogeneic bone marrow, autologous and allogeneic peripheral stem cell and allogeneic cord blood transplants:(a)
Irreversible terminal state (moribund or on life support);(b)
An irreversible disease of any other major organ system likely to limit life expectancy to five (5) years or less;(c)
Positive HIV test results;(d)
Positive pregnancy test.(5)
The following may be considered contraindications to the extent the evaluating transplant center and/or the specialist who completed the comprehensive evaluation of the client believe these condition(s) may interfere significantly with the recovery process:(a)
Serious psychological disorders;(b)
Alcohol or drug abuse.(6)
The Division of Medical Assistance Programs (Division) will prior authorize and reimburse for autologous and allogeneic bone marrow, autologous and allogeneic peripheral stem cell and allogeneic cord blood transplants only 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.(7)
The Division will prior authorize and reimburse for autologous and allogeneic bone marrow, autologous and allogeneic peripheral stem cell and allogeneic cord blood transplants for pediatric solid malignancies only if:(a)
Requirements of 410-124-0080 (Criteria and Contraindications for Autologous and Allogeneic Bone Marrow, Autologous and Allogeneic Peripheral Stem Cell and Allogeneic Cord Blood Transplants)(6)(a), (b) and (c) are met; and(b)
There is documentation of a morphology code listed on the currently funded line for pediatric solid tumor in the Prioritized List of Health Services adopted under OAR 410-141-0520.(8)
Prior authorization for harvesting of autologous bone marrow or peripheral stem cells does not guarantee reimbursement for the transplant; the patient must meet the criteria specified above and in 410-124-0020 (Prior Authorization for All Covered Transplants, Except Cornea and Kidney) at the time the transplant is performed.
Source:
Rule 410-124-0080 — Criteria and Contraindications for Autologous and Allogeneic Bone Marrow, Autologous and Allogeneic Peripheral Stem Cell and Allogeneic Cord Blood Transplants, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-124-0080.