23 Miss. Code. R. 202-4.13

Current through December 10, 2024

Rule 23-202-4.13 - Liver Transplant

A. Prior authorization is required.

B. Liver transplants are covered when the following criteria are met:

1. Candidate is less than sixty-five (65) years of age.

2. Model for End Stage Liver Disease (MELD) score.

3. Pediatric End Stage Liver Disease (PELD) score.

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

5. Infection controlled for at least forty-eight (48) hours prior to transplant.

6. Absence of severe and irreversible end organ dysfunction, either cardiac, pulmonary, renal, peripheral vascular, or cerebrovascular, or uncontrolled extrahepatic 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.

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

13. Specific Diagnostic Inclusion Criteria

a) Chronic progressive liver disease, not otherwise correctable, including cirrhosis due to: alcoholism, if abstinent at least the prior six (6) months, chronic hepatitis C, primary or secondary biliary disease, sclerosing cholangitis, inborn error of metabolism, or other causes.

b) Non-cirrhotic liver failure due to: biliary atresia, fulminant liver failure, submassive hepatic necrosis, hepatoblastoma, Budd-Chiari syndrome, an obstruction of the hepatic veins if associated with a treatable disorder.

c) Hepatocellular carcinoma, in conjunction with chemotherapy, if there is no evidence of extrahepatic metastases.

14. Facility is approved for liver transplants by the Division of Medicaid.

B. Liver 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. Acute alcoholic hepatitis.

3. Uncorrectable hemodynamic instability.

4. Extensive and uncorrectable portal vein thrombosis precluding portal inflow to graft.

5. Extrahepatic malignancy or hepatic malignancy with extrahepatic metastases.

6. Severe terminal diabetic and organ disease.

7. HIV.

8. Uncorrectable absence of an essential psychosocial support system.

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

23 Miss. Code. R. 202-4.13

Miss. Code Ann. § 43-13-121; 42 CFR §482.90 - 104; 56 FR 15006