Or. Admin. R. 410-124-0065 - Criteria and Contraindications for Single Lung Transplants

Current through Register Vol. 60, No. 12, December 1, 2021

(1) Prior authorization for a single lung transplant will only be approved for a client in whom irreversible lung 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) The client must have a poor prognosis (i.e., less than a 50% chance of survival for 18 months without a transplant) as a result of poor pulmonary functional status.
(3) All alternative medically accepted treatments that have a one year survival rate comparable to that of single lung transplantation must have been tried or considered.
(4) Requests for transplant services for children suffering from early pulmonary disease may be approved before attempting alternative treatments if medical evidence suggests an early date of transplant is likely to improve the outcome.
(5) A client with one or more of the following contraindications is ineligible for single lung transplant services:
(a) Untreatable systemic vasculitis;
(b) Incurable malignancy;
(c) Diabetes with end-organ damage;
(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.
(6) 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 recovery process:
(a) Hyperlipoproteinemia;
(b) Curable malignancy;
(c) Significant cerebrovascular or peripheral vascular disease;
(d) Unresolved continuing thromboembolic disease or pulmonary infarction;
(e) Serious psychological disorders;
(f) Drug or alcohol abuse.
(7) The Division of Medical Assistance Programs (Division) will only prior authorize and reimburse for single lung transplants 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.

Notes

Or. Admin. R. 410-124-0065
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 21-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 34-2001, f. 9-24-01, cert. ef. 10-1-01; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

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