23 Miss. Code R. § 202-4.10

Current through May 31, 2024

Rule 23-202-4.10 - Heart Transplant

A. Prior authorization is required.

B. Heart transplants are covered when all the following criteria are met:

1. Candidate is less than sixty-six (66) years of age.

2. New York Heart Association (NYHA) Class III or IV on maximal medical therapy.

3. Meets transplanting facility's blood and tissue-type compatibility standards.

4. Infections are controlled for at least forty-eight (48) hours prior to transplant.

5. Pulmonary Functions studies of FEV1 of >1.5 liter, PVR of <3 Wood units (if >3, prior to vasodilators, <3 after), Pulmonary artery systolic pressure <65-70 mm Hg.

6. Absence of irreversible and severe end organ dysfunction, such as hepatic, renal, peripheral vascular, or cerebrovascular, as well as, refractory hypertension, or uncontrolled malignancy.

7. All other treatments have been attempted or considered and none will prevent progressive disability and/or death.

8. The candidate and/or legal representative understands the transplant risks and benefits, gives informed consent, and has the capacity and is willing to comply with needed care, including immunosuppressive therapy.

9. The candidate has been approved by the transplant review team.

10. Required serology studies have been completed for HIV, Hepatitis A, B, and C, Cytomegalovirus (CMV), and Varicella.

11. Immunizations have been administered as follows:

a) All immunizations for children age two (2) to six (6) are up-to-date in accordance with the most current recommended childhood immunization schedule developed and endorsed by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),

b) Hepatitis A, if serology does not indicate immunity,

c) Hepatitis B, if serology does not indicate immunity,

d) Pneumococcal, and

e) Influenza, annually.

12. A psychosocial evaluation has been performed for the adult candidate or, if the candidate is a child, for the family, with the following results:

a) Candidate's psychiatric disorders, if present, are being treated,

b) Candidate's social support system has been evaluated and found to be adequate, and

c) Candidate has no previous history of significant non-compliance to medical treatment.

13. Specific diagnostic inclusion criteria include the following conditions if expected to limit the candidate's survival rate to less than twelve (12) months:

a) Congestive, restrictive, or ischemic cardiomyopathy,

b) Valvular, congenital and other organic heart disease,

c) Recurrent and refractory life-threatening ventricular dysrhythmias, or

d) Refractory severe angina pectoris.

14. The facility is approved for heart transplants.

C. Transplants are not covered when the candidate has one (1) of the following:

1. Active chemical dependency, drugs or alcohol, within the preceding six (6) months.

2. Gastrointestinal hemorrhage.

3. Severe and irreversible pulmonary, for instance FEV1 < 1 liter, or other non-cardiac organ dysfunction.

4. Recent or unresolved pulmonary infarction, not embolism.

5. Uncorrectable absence of an essential psychosocial support system.

6. Unmanageable psychiatric disorder felt to significantly compromise compliance with the post-transplant regimen.

7. HIV.

8. Hepatitis B or Hepatitis C.

9. Systemic malignancy.

23 Miss. Code. R. § 202-4.10

Miss. Code Ann. § 43-13-121; 42 CFR 482.90 -104; 52 FR 10935