23 Miss. Code R. § 202-4.15

Current through May 31, 2024

Rule 23-202-4.15 - Bilateral Lung Transplant

A. Prior Authorization is required.

B. Bilateral lung transplants are covered when the following criteria are met:

1. Candidate is less than sixty-one (61) years of age.

2. NYHA Class III or IV with rehabilitation potential.

3. Preserved nutritional state.

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

5. Infections controlled for at least forty-eight (48) hours prior to transplant, unless the infection is limited to the lung to be removed.

6. Absence of irreversible and severe end organ dysfunction, either hepatic, gastrointestinal, renal, peripheral vascular, or cerebrovascular), 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 center's 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.

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.

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

13. Specific Diagnostic Inclusion Criteria:

a) End-stage fibrotic lung disease unresponsive to alternative therapy with FVC <65% of predicted.

b) End-stage obstructive lung disease with FVC <25% of predicted.

c) End-stage pulmonary hypertension, either primary or secondary without significant right heart dysfunction, unless heart-lung transplant planned

d) Cystic fibrosis with FVC <40% and FEV1 <30% of predicted.

e) Bronchiectasis.

f) Bronchopulmonary dysplasia.

g) Obliterative bronchiolitis.

14. Facility is approved for lung transplants by Medicaid.

C. Bilateral lung transplants are not covered when the candidate has one of the following:

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

2. Steroid therapy >20mg/day, must be off steroids or weanable from them.

3. Bone marrow failure of any stem line: RBC, WBC, platelets.

4. Severe osteoporosis.

5. Severe chest wall deformity

6. Cachexia, body weight <70% of ideal for height, or obesity, body weight >120% of ideal for height, in candidates with Cystic Fibrosis.

7. Recent pulmonary embolism or current deep venous thrombosis.

8. Viral hepatitis in candidates with Cystic Fibrosis.

9. HIV.

10. Uncorrectable absence of an essential psychosocial support system.

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

23 Miss. Code. R. § 202-4.15

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