1.0 CPT 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.
2.1.2 The contractor shall reimburse
charges for the services on a Point of Service (POS) basis, if Prime enrollees
receive transplant-related services from non-network civilian providers
without the required PCM referral and contractor authorization.
Special cost-sharing requirements apply to POS claims.
2.1.3 The contractor shall be the
preauthorization authority for TRICARE Standard and TRICARE Extra patients
(through December 31, 2017) and TRICARE Select enrollees (starting
January 1, 2018) residing in its geographic area of responsibility.
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 United States (US) 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.