Or. Admin. R. 410-124-0100 - Criteria and Contraindications for Liver and Liver-Kidney Transplants

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

(1) Prior authorization for liver or liver-kidney transplants will be approved only for a client in whom irreversible, progressive 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 20 percent as supported by medical literature.
(2) Liver-kidney transplant is covered only for a medically documented diagnosis of Caroli's disease (ICD-10-CM Q44.6).
(3) The following are contraindications for liver or liver-kidney transplants:
(a) Incurable and untreatable malignancy outside the hepatobiliary system;
(b) Terminal state due to diseases other than liver disease;
(c) Uncontrolled sepsis, or active systemic infection;
(d) HIV positive test results;
(e) Active alcoholism or active substance abuse;
(f) Alternative effective medical or surgical therapy;
(g) Presence of uncorrectable significant organ system failure other than liver (excluding short-bowel syndrome or congenital intractable diarrhea).
(4) 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 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, not correctable congenital anomalies;
(e) Serious psychological disorders.
(5) The transplant center will review for current risk of alcohol or other substance abuse and risk of recidivism and will inform the Division of Medical Assistance Programs (Division) of its findings prior to the provision of the transplant.
(6) The Division will only prior authorize and reimburse for liver and liver-kidney 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. 410-124-0100
HR 8-1990(Temp), f. 3-30-90, cert. ef. 4-1-90; HR 22-1990, f. & cert. ef. 7-17-90; HR 17-1992, f. & cert. ef. 7-1-92; 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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