4.228 Transplantation Services.
(5/1/2023, GCR 22-099)
4.228.1 Definitions
For the purposes of this rule, the term:
"Transplantation services" means a medical procedure
performed to replace a diseased or damaged body part with a healthy
one.
4.228.2 Covered
Services
Vermont Medicaid covers medically necessary transplantation
services for the beneficiary including harvesting, preservation, and
transportation of cadaver organs. Vermont Medicaid also covers, under the
Medicaid of the person receiving the transplantation, medically necessary
transplantation services for live donors, including post transplantation
services and transportation.
4.228.3 Qualified Providers
Providers must be working within the scope of their practice
and enrolled in Vermont Medicaid. Providers must also be certified by the
American Society of Transplant Surgeons (ASTS) and maintain their membership in
good standing and experienced in postoperative care and management of an
immunosuppressive regimen.
4.228.4 Qualified Facilities
The transplant facility must meet the following
criteria:
(a) Be fully accredited as a
transplant center by applicable state and federal agencies.
(b) Be in compliance with all applicable
state and federal laws which apply to organ acquisition and transplantation
including equal access and non-discrimination laws.
(c) Have an interdisciplinary team to
determine the suitability of candidates for transplantation on an equitable
basis.
(d) At the time Medicaid
coverage is requested, the center must provide current documentation that it
provides high quality care relative to other transplant centers.
(e) Provides all medically necessary services
required including management of complications of the transplantation and late
infection and rejection episodes. Failure of the transplant is considered a
complication and re-transplantation must be available at the center.
4.228.5 Conditions for Coverage
The Medicaid beneficiary must meet the following
conditions:
(a) The Medicaid
beneficiary has a condition for which transplantation is the appropriate
treatment.
(b) All other medically
feasible forms of medical or surgical treatment have been considered, and the
most effective and appropriate medically indicated alternative for the
beneficiary is transplantation services.
(c) The Medicaid beneficiary meets all
medical criteria for the proposed type of transplantation based upon the
prevailing standards and current practices. These would include, but are not
limited to:
(1) Test lab results within
identified limits to assure successful transplantation and recovery.
(2) Diagnostic evaluations of the
beneficiary's medical and mental health that indicate there will be no
significant adverse effect upon the outcome of the transplantation.
(3) Assessment of other relevant factors that
might affect the clinical outcome or adherence to an immunosuppressive regimen
and rehabilitation program following the transplant.
(4) The beneficiary or an individual
authorized to make health care decisions on the beneficiary's behalf has been
fully informed of the risks and benefits of the proposed transplant including
the risks of complications, continuing care requirements, and the expected
quality of life after the procedure.
4.228.5 Prior Authorization
The Vermont Medicaid fee schedule contains a detailed list of
covered services and indicates which services require prior authorization. The
fee schedule can be found on the Department of Vermont Health Access
website.
4.228.6 Non-Covered
Services
Transplantation services are not covered if the procedure is
experimental or investigational.
