OAR 410-124-0105
Criteria and Contraindications for Intestine and Intestine-Liver Transplants
(1)
Prior authorization for intestine and intestine-liver transplants will be approved only for:(a)
A client who has failed Total Parenteral Nutrition (TPN) or who has developed life-threatening complications from TPN;(b)
A client in whom irreversible, progressive intestine and/or liver 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 twenty (20) percent as supported by the medical literature.(2)
Intestine and Intestine-Liver transplant is covered only for a medically documented diagnosis of Short Bowel Syndrome and for patients age 5 years or under with diagnosis of ICD-10-CM K55.0-K55.9, ICD-10-CM K91.2, or ICD-10-CM P77.9.(3)
Small intestine transplant using a living related donor is considered investigational and will not be covered by The Division of Medical Assistance Programs (Division).(4)
The following are contraindications for intestine or intestine-liver transplants:(a)
Incurable and untreatable malignancy outside the hepatobiliary system;(b)
Terminal state due to diseases other than liver or intestinal disease;(c)
Uncontrolled sepsis, or active systemic infection;(d)
HIV positive test results;(e)
Alternative effective medical or surgical therapy;(f)
Presence of uncorrectable significant organ system failure other than liver or Short-Bowel Syndrome.(5)
The following may be considered contraindications to the extent that the evaluating transplant center and/or specialist who completed the comprehensive evaluation of the client believe these condition(s) may interfere significantly with the recovery process:(a)
Crigler-Najjar Syndrome Type II;(b)
Amyloidosis;(c)
Other major system diseases affecting brain, lung, heart, or renal systems;(d)
Major, non-correctable congenital anomalies;(e)
Serious psychological disorders.(6)
The Division will prior authorize and reimburse for intestine and intestine-liver transplant 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 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 410-124-0105 — Criteria and Contraindications for Intestine and Intestine-Liver Transplants, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-124-0105.