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.