Utah Admin. Code R414-10A-11 - Requests for Non-Covered Transplantation Services
Requests for non-covered services are considered based on evidence submitted as to the efficacy of the requested services. These requests are reviewed on a case -by -case basis and require Medicaid Director or designee approval. Evidence types may include, but are not limited to:
(1) Evidence published in peer-reviewed
medical journals listed on the Centers for Medicare and Medicaid Services (CMS)
website.
(2) Evidence of
acceptable survival rates with the proposed protocol in groups with similar
clinical characteristics to the patient:
(a)
The current survival rate threshold is at least 75 percent one-year survival
and at least 55 percent three-year survival; or
(b) Similar characteristics include age,
tumor type, tumor size, resection status, presence of metastases, etc.
(3) Study size with
sufficient number of individuals for statistical analysis; or
(4) Evidence that the proposed protocol is a
less costly alternative to other potential treatment protocols.
Notes
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