Section 13 174 011 - TRANSPLANTATION SERVICES4.228 Transplantation Services. (5/1/2023, GCR 22-099)
4.228.1 Definitions For the purposes of this rule, the term:
"Transplantation services" means a medical procedure performed to replace a diseased or damaged body part with a healthy one.
4.228.2 Covered Services Vermont Medicaid covers medically necessary transplantation services for the beneficiary including harvesting, preservation, and transportation of cadaver organs. Vermont Medicaid also covers, under the Medicaid of the person receiving the transplantation, medically necessary transplantation services for live donors, including post transplantation services and transportation.
4.228.3 Qualified Providers Providers must be working within the scope of their practice and enrolled in Vermont Medicaid. Providers must also be certified by the American Society of Transplant Surgeons (ASTS) and maintain their membership in good standing and experienced in postoperative care and management of an immunosuppressive regimen.
4.228.4 Qualified Facilities The transplant facility must meet the following criteria:
(a) Be fully accredited as a transplant center by applicable state and federal agencies.(b) Be in compliance with all applicable state and federal laws which apply to organ acquisition and transplantation including equal access and non-discrimination laws.(c) Have an interdisciplinary team to determine the suitability of candidates for transplantation on an equitable basis.(d) At the time Medicaid coverage is requested, the center must provide current documentation that it provides high quality care relative to other transplant centers.(e) Provides all medically necessary services required including management of complications of the transplantation and late infection and rejection episodes. Failure of the transplant is considered a complication and re-transplantation must be available at the center.4.228.5 Conditions for Coverage The Medicaid beneficiary must meet the following conditions:
(a) The Medicaid beneficiary has a condition for which transplantation is the appropriate treatment.(b) All other medically feasible forms of medical or surgical treatment have been considered, and the most effective and appropriate medically indicated alternative for the beneficiary is transplantation services.(c) The Medicaid beneficiary meets all medical criteria for the proposed type of transplantation based upon the prevailing standards and current practices. These would include, but are not limited to:(1) Test lab results within identified limits to assure successful transplantation and recovery.(2) Diagnostic evaluations of the beneficiary's medical and mental health that indicate there will be no significant adverse effect upon the outcome of the transplantation.(3) Assessment of other relevant factors that might affect the clinical outcome or adherence to an immunosuppressive regimen and rehabilitation program following the transplant.(4) The beneficiary or an individual authorized to make health care decisions on the beneficiary's behalf has been fully informed of the risks and benefits of the proposed transplant including the risks of complications, continuing care requirements, and the expected quality of life after the procedure.4.228.5 Prior Authorization The Vermont Medicaid fee schedule contains a detailed list of covered services and indicates which services require prior authorization. The fee schedule can be found on the Department of Vermont Health Access website.
4.228.6 Non-Covered Services Transplantation services are not covered if the procedure is experimental or investigational.
13-011 Code Vt. R. 13-174-011-X
EFFECTIVE DATE:
December 1, 1980 Secretary of State Rule Log #80-123
AMENDED:
October 1, 2008 Secretary of State Rule Log #08-040; 5/1/2023 Secretary of State Rule Log #23-008STATUTORY AUTHORITY:
3 V.S.A. § 801; 33 V.S.A. § 1901