Current through Register Vol. 60, No. 12, December 1, 2021
authorization for a heart-lung transplant will only be approved for a client in
whom irreversible cardio-pulmonary 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-lung
transplant must have cardio-pulmonary failure with 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-lung transplantation must have been tried or considered.
(4) Requests for transplant services for
children suffering from early cardio-pulmonary disease may be approved before
attempting alternative treatments if medical evidence suggests an early date of
transplant is likely to improve the outcome.
A client with one or more of the
following contraindications is ineligible for heart-lung transplant services:
(a) Untreatable systemic vasculitis;
(b) Incurable malignancy;
(c) Diabetes with end-organ
(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.
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
(b) Curable malignancy;
(c) Significant cerebrovascular or peripheral
or continuing thromboembolic disease or pulmonary infarction;
(e) Serious psychological disorders;
(f) Drug or alcohol abuse.
The Division of
Medical Assistance Programs (Division) will only prior authorize and reimburse
for heart-lung transplants if:
Division criteria are met; and
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
Or. Admin. R.
HR 4-1994, f. & cert.
ef. 2-1-94; HR 19-1995, f. 9-28-95, cert. ef. 10-1-95; OMAP 18-2000 f. 9-28-00,
cert. ef. 10-1-00; OMAP 34-2001, f. 9-24-01, cert. ef. 10-1-01;
51-2015, f. 9-22-15, cert. ef.
Stat. Auth.: ORS
Stats. Implemented: ORS