Current through Register Vol. 60, No. 12, December 1, 2021
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).
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
sepsis, or active systemic infection;
(d) HIV positive test results;
(e) Active alcoholism or active substance
(f) Alternative effective
medical or surgical therapy;
Presence of uncorrectable significant organ system failure other than liver
(excluding short-bowel syndrome or congenital intractable diarrhea).
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
(a) Crigler-Najjar Syndrome Type II;
(c) Other major system diseases affecting
brain, lung, heart, or renal systems;
(d) Major, not correctable congenital
(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.
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;
(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 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.
51-2015, f. 9-22-15, cert. ef.
Stat. Auth.: ORS
Stats. Implemented: ORS