(1) The medicaid agency pays for medically necessary transplant procedures only for eligible Washington apple health clients who are not otherwise subject to a managed care organization (MCO) plan. Clients eligible under the alien emergency medical (AEM) program are not eligible for transplant coverage.

(2) The agency covers the following transplant procedures when the transplant procedures are performed in a hospital designated by the agency as a "center of excellence" for transplant procedures and meet that hospital's criteria for establishing appropriateness and the medical necessity of the procedures:

(a) Solid organs involving the heart, kidney, liver, lung, heart-lung, pancreas, kidney-pancreas, and small bowel;

(b) Bone marrow and peripheral stem cell (PSC);

(d) Corneal transplants.

(3) For procedures covered under subsections (2)(a) and (b) of this section, the agency pays facility charges only to those hospitals that meet the standards and conditions:

(a) Established by the agency; and

(b) Specified in WAC 182-550-2100 and 182-550-2200.

(4) The agency pays for skin grafts and corneal transplants to any qualified hospital, subject to the limitations in this chapter.

(5) The agency deems organ procurement fees as being included in the payment to the transplant hospital. The agency may make an exception to this policy and pay these fees separately to a transplant hospital when an eligible medical client is covered by a third-party payer that will pay for the organ transplant procedure itself but not for the organ procurement.

(6) The agency, without requiring prior authorization, pays for up to fifteen matched donor searches per client approved for a bone marrow transplant. The agency requires prior authorization for matched donor searches in excess of fifteen per bone marrow transplant client.

(7) The agency does not pay for experimental transplant procedures. In addition, the agency considers as experimental those services including, but not limited to, the following:

(a) Transplants of three or more different organs during the same hospital stay;

(b) Solid organ and bone marrow transplants from animals to humans; and

(c) Transplant procedures used in treating certain medical conditions for which use of the procedure has not been generally accepted by the medical community or for which its efficacy has not been documented in peer-reviewed medical publications.

(8) The agency pays for a solid organ transplant procedure only once per client's lifetime, except in cases of organ rejection by the client's immune system during the original hospital stay.

(9) The agency pays for bone marrow, PSC, skin grafts, and corneal transplants when medically necessary.

(10) The agency may conduct a postpayment retrospective utilization review as described in WAC 182-550-1700, and may adjust the payment if the agency determines the criteria in this section are not met.

PDFWAC 182-550-1900

Transplant coverage.