23 Miss. Code. R. 202-4.16 - Bone Marrow Transplant
A. Medicaid covers
bone marrow transplants as noted below and does not require prior authorization
for medical necessity from the UM/QIO.
B. Bone marrow transplants (BMT), Autologous,
Syngeneic, or Allogeneic, are covered for inpatient and outpatient when the
following criteria are met:
1. Candidate is
less than fifty-six (56) years of age for allogeneic, < sixty-six (66) if
fully matched sibling donor.
2.
Candidate is less than seventy (70) years of age for autologous.
3. Karnofsky >70 or ECOG <3.
4. Allogeneic HLA-MLC match, 1 antigen
mismatch accepted.
5. Infections
controlled for forty-eight (48) hours prior to transplant.
6. Left ventricular ejection fraction
>40%.
7. FEV1 of >50% of
predicted.
8. Dlco >60% of
predicted.
9. All other treatments
have been attempted or considered and none will prevent progressive disability
and/or death.
10. The candidate
and/or legal representative understands the transplant risks and benefits,
gives informed consent, and has the capacity and is willing to comply with
needed care, including immunosuppressive therapy.
11. The candidate has been approved by the
transplant review team.
12. The
candidate's immunization history and HIV status has been obtained.
13. A psychosocial evaluation has been
performed for the adult candidate or, if the candidate is a child, for the
family, with the following results:
a)
Candidate's psychiatric disorders, if present, are being treated.
b) Candidate's social support system has been
evaluated and found to be adequate.
c) Candidate has no previous history of
significant non-compliance to medical treatment.
14. Specific Diagnostic Inclusion Criteria
(Allogeneic BMT or PSCT)
a) Severe aplastic
anemia.
b) Pure erythrocyte
aplasia.
c)
Myelodysplasia.
d) Severe
hemoglobinopathy, including sickle cell, thalassemia.
e) Selected immunodeficiency syndrome
including SCID, Wiskott-Aldrich, Chediak-Higashi
f) Genetic storage disease, including
Hurler's, Morquio's.
g) Primary
amyloidosis.
h) Paroxysmal
nocturnal hemoglobinuria.
i) Severe
platelet dysplasia.
j) Acute
lymphocytic leukemia, in first remission if high risk, at early relapse, or in
second remission.
k) Acute
myelogenous leukemia, in same clinical states as listed for acute lymphocytic
leukemia.
l) Chronic lymphocytic
leukemia.
m) Chronic myelogenous
leukemia.
n) Hodgkin's lymphoma,
failed first line therapy or failed at least one standard chemotherapy
regimen.
o) Non-Hodgkin's lymphoma
failed or responsive to first line therapy or high risk during first
remission.
p) Familial
hemophagocytic lymphohistiocytosis (FHL) also known as familial
erythrophagocytic.
q)
Lymphohistiocytosis (FEL).
15. Specific Diagnostic Inclusion Criteria
(Autologous BMT or PSCT)
a) Acute lymphocytic
leukemia in first remission if high risk, at early relapse, or in second
remission.
b) Acute myelogenous
leukemia in same clinical states as listed for acute lymphocytic
leukemia.
c) Chronic lymphocytic
leukemia.
d) Chronic myelogenous
leukemia.
e) Hodgkin's lymphoma,
for failed first line therapy or if failed at least one standard chemotherapy
regimen.
f) Multiple Myeloma-a
single autologous BMT/SCT transplant will be considered for beneficiaries with
Durie-Salmon stage II or stage III disease if the following criteria is met.
Newly diagnosed disease or responsive multiple myeloma. This includes
beneficiaries with previously untreated disease, those with at least a partial
response to prior chemotherapy, which is defined as 50% decrease in either
measurable serum and/or urine paraprotein or in bone marrow infiltration,
sustained for at least one (1) month, and those in responsive relapse with
adequate renal, pulmonary, and hepatic function.
16. Tandem BMT/SCT for multiple myeloma is
specifically excluded from coverage.
a)
Non-Hodgkin's lymphoma, either failed or responsive to first line therapy or,
if high risk, during first remission
b) Neuroblastoma.
c) Nephroblastoma.
17. Transplant facilities must meet Medicaid
facility criteria.
C.
Bone marrow transplants are not covered if the candidate has one (1) of the
following:
1. Active chemical dependency,
drugs or alcohol, within the preceding six (6) months
2. HIV.
3. Breast cancer.
4. Uncorrectable absence of an essential
psychosocial support system.
5.
Unmanageable psychiatric disorder felt to significantly compromise the
candidate's compliance with the post-transplant regimen.
Notes
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No prior version found.