(1) Prior
authorization (PA) may be required for any transplantation service.
(a) To determine if PA is required, refer to
the Utah Medicaid Coverage and Reimbursement Code Lookup tool.
(2) The Department's
evidence-based criteria may be used, when available, as part of the PA process.
(3) If PA is required, the request
must include documentation that the patient meets the organ specific
requirements in this rule.
(4) The
PA request for transplantation services must include:
(a) A description of condition needing
transplantation;
(b)
Transplantation treatment alternatives utilized previous to the transplant
request;
(c) Transplantation
treatment alternatives considered and discarded, including rationale for
discarding;
(d) A comprehensive
examination, evaluation and recommendation completed by a Board-Certified or
Board-Eligible specialist and medical and surgical specialists in the field
directly related to the patient's condition , which demonstrates the need for a
transplant. The patient must also demonstrate the ability to tolerate the
proposed transplant and subsequent treatment regimen;
(e) A comprehensive psycho-social evaluation
of the patient that includes:
i. motivation
for transplant;
ii. willingness
and ability to follow a long-term treatment and follow-up regimen; and
iii. history of active substance
use.
(f) If the patient
is less than 18 years of age, a comprehensive psycho-social evaluation of the
patient's parent or guardian that includes:
i. motivation for transplant;
ii. willingness and ability to follow a
long-term treatment and follow-up regimen; and
iii. history of active substance use.
(g) A comprehensive
psychiatric evaluation, if the patient has a history of mental illness.
(h) Documentation of a
successfully completed treatment program or abstinence, if the patient has a
history of substance use.
(i)
Treatment program success and abstinence are supported by negative drug screens
for a minimum of six months, with two negative drug screens in the most recent
three months. The timing of the drug screens is in relation to the PA request
date.
(j) If the history of
substance use involves drugs other than those listed in this rule under Section
R414-10A-2, then the
drug screens must include the other substance upon drug testing availability.
(k) The patient may not be an
active substance user as defined under Section
R414-10A-2.
(l) Comprehensive infectious
disease evaluation for a patient with a recent or current suspected infectious
episode.
(m) All applicable
hospital and clinic records.
(n)
Completed cancer screening tests.
(o) All relevant laboratory and imaging
studies.
(p) Documentation that
the patient meets the eligibility and selection criteria for the transplant
facility where the transplant will be performed.
(q) Any other documentation requested by PA
or the Department's physician consultants.
(5) If incomplete documentation is received
by the Department, the patient's case is pended until the requested
documentation has been received.
(6) If a transplant requiring PA is performed
without PA, reimbursement may be denied for all services related to the
transplant up to the outlier threshold days for the specific type of
transplant.
(7) Refer to the
Section I: General Information Provider Manual for retroactive authorization
for emergency transplant services.