1.0 CPT
PROCEDURE CODES
47133 - 47135, 50300, 50340,
50360, 50365
2.0 POLICY
2.1 Benefits
are allowed for CLKT.
2.1.1 A TRICARE Prime enrollee must have a referral
from their Primary Care Manager (PCM) and an authorization from
the contractor before obtaining transplant-related services. If
network providers furnish transplant-related services without prior
PCM referral and contractor authorization, penalties will be administered
according to TRICARE network provider agreements. If Prime enrollees
receive transplant-related services from non-network civilian providers
without the required PCM referral and contractor authorization,
contractors shall reimburse charges for the services on a Point
of Service (POS) basis. Special cost-sharing requirements apply
to POS claims.
2.1.2 For Standard and Extra patients (through
December 31, 2017) and TRICARE Select enrollees (starting January
1, 2018) residing in a Managed Care Support (MCS)
region, preauthorization authority is the responsibility of the
MCS Medical Director or other designated utilization staff.
2.2 CLKT is
covered when the transplant is performed at a TRICARE or Medicare-certified
liver transplant center or TRICARE-certified pediatric consortium
liver transplantation center, for beneficiaries who:
2.2.1 Are suffering from concomitant,
irreversible hepatic and renal failure; and
2.2.2 Have exhausted
more conservative medical and surgical treatments for hepatic and
renal failure.
2.2.3 Have plans for long-term adherence
to a disciplined medical regimen that are feasible and realistic.
2.3 Transplants
performed for beneficiaries suffering from hepatic failure resulting
from hepatitis B or C are covered.
2.4 Services and supplies related
to CLKT are covered for:
2.4.1 Evaluation of a potential
candidate’s suitability for CLKT whether or not the patient is ultimately
accepted as a candidate for transplantation.
2.4.2 Pre- and
post-transplant inpatient hospital and outpatient services.
2.4.3 Pre- and
post-operative services of the transplant team.
2.4.4 The donor
acquisition team, including the costs of transportation to the location
of the donor organ and transportation of the team and the donated
organ to the location of the transplantation center.
2.4.5 The maintenance
of the viability of the donor organ after all existing legal requirements
for excision of the donor organ have been met.
2.4.6 Donor costs.
2.4.7 Blood and
blood products.
2.4.8 U.S. Food and Drug Administration
(FDA) approved immunosuppression drugs to include off-label uses
when reliable evidence documents that the off-label use is safe,
effective and in accordance with the national standards of practice
in the medical community (proven).
2.4.9 Complications of the transplant
procedure, including inpatient care, management of infection and
rejection episodes.
2.4.10 Periodic
evaluation and assessment of the successfully transplanted patient.
2.4.11 Hepatitis
B and pneumococcal vaccines for patients undergoing transplantation.
2.4.12 Deoxyribonucleic
Acid-Human Leucocyte Antigen (DNA-HLA) tissue typing in determining histocompatibility.
2.4.13 Transportation
of the patient by air ambulance and the services of a certified
life support attendant.
3.0 POLICY
CONSIDERATIONS
3.1 In those cases where the beneficiary fails
to obtain preauthorization, benefits may be extended if the services
or supplies otherwise would qualify for benefits but for the failure
to obtain preauthorization. If preauthorization is not received,
the appropriate preauthorizing authority is responsible for reviewing
the claims to determine whether the beneficiary’s condition meets
the clinical criteria for the CLKT benefit. Charges for transplant
and transplant-related services provided to TRICARE Prime enrollees
who failed to obtain PCM referral and contractor authorization will
be reimbursed only under POS rules.
3.2 Benefits will only be allowed
for transplants performed at a TRICARE or Medicare-certified liver transplantation
center. Benefits are also allowed for transplants performed at a
pediatric facility that is TRICARE-certified as a liver transplantation
center on the basis that the center belongs to a pediatric consortium
program whose combined experience and survival data meet the TRICARE
criteria for certification. The contractor in whose jurisdiction
the center is located is the certifying authority for TRICARE approval
as a liver transplantation center. Refer to
Chapter 11, Section 7.1 for organ transplant center
certification requirements.
3.3 CLKTs shall be paid under
the assigned Diagnosis Related Group (DRG) based on the patient’s diagnosis.
3.4 Claims
for transportation of the donor organ and transplant team shall
be adjudicated on the basis of billed charges, but not to exceed
the transport service’s published schedule of charges, and cost-shared
on an inpatient basis. Scheduled or chartered transportation may
be cost-shared.
3.5 Acquisition and donor costs
are not considered to be components of the services covered under
the DRG. These costs must be billed separately on a standard Centers
for Medicare and Medicaid Services (CMS) 1450 UB-04 claim form in
the name of the TRICARE patient.
3.6 When a properly preauthorized
candidate is discharged less than 24-hours after admission because
of extenuating circumstance, such as the available organ is found
not suitable or other circumstances which prohibit the transplant
from being timely performed, all otherwise authorized services associated
with the admission shall be cost-shared on an inpatient basis, since
the expectation at admission was that the patient would remain more
than 24 hours.
3.7 CLKTs performed on an emergency basis in an
unauthorized liver transplant facility may be cost-shared only when
the following conditions have been met:
3.7.1 The unauthorized center must
consult with the nearest TRICARE or Medicare-certified liver transplantation
center regarding the transplantation case; and
3.7.2 It must
be determined and documented by the transplant team physician(s)
at the certified liver transplantation center that transfer of the
patient (to the certified liver transplantation center) is not medically
reasonable, even though transplantation is feasible and appropriate.
3.8 This policy
does not apply to beneficiaries who become eligible for Medicare
coverage due to isolated renal disease. This policy applies only
to those individuals suffering from concomitant hepatic and renal
failure. Coordination of benefits with Medicare is not required
for CLKTs.
4.0 EXCLUSIONS
4.1 CLKT is
excluded when the following contraindications exist:
4.1.1 Significant systemic or multisystemic
disease (other than hepatorenal failure) which limits the possibility
of full recovery and may compromise the function of the newly transplanted
organs.
4.1.2 Active alcohol or other substance abuse that
interferes with compliance to strict treatment regimen.
4.1.3 Malignancies
metastasized to or extending beyond the margins of the liver and/or
kidney.
4.2 The following are also excluded:
4.2.1 Expenses
waived by the transplant center, (i.e., beneficiary/ sponsor not
financially liable).
4.2.2 Services and supplies not
provided in accordance with applicable program criteria, (i.e., part
of a grant or research program, unproven procedure).
4.2.3 Administration
of an unproven immunosuppressant drug that is not FDA approved or
has not received approval as an appropriate “off-label” drug indication.
4.2.4 Pre- or
post-transplant nonmedical expenses (i.e., out-of-hospital living
expenses, to include, hotel, meals, privately owned vehicle for
the beneficiary or family members).
4.2.5 Transportation of an organ
donor.
5.0 EFFECTIVE
DATES
5.1 November 12, 1992.
5.2 November 1, 1994, for hepatitis
C.
5.3 December 1, 1996, for hepatitis B.